mam 
Hi 



m 



WB& 






II 

In 



^ 



Mm 

B888S a&SSSSwSs 

111 ■ 



:■•■.-•■.•■■ 

1 

JHHmimfc,t« 8EEBg8 S S E a 



aHHBS2£i&*A^*: 



•'-•:■::•■■ 



;■;,-' 



llMi 



:«&? 



SK 






■ ■:•. a 
SSS& 



&8saK$&'&&'<' 



3§§§Si 



■ : : i^ :", ■ 



i 



. 




Xeroderma Pigmentosum. 

i a painting in oil.) 



A PRACTICAL TREATISE 



DISEASES OF THE SKIN 



FOR THE USE OF 



STUDENTS AND PRACTITIONERS 



/JAMES NEVINS HYDE, A.M., M.D. 

)FESSOR OF DERMATOLOGY IN RUSH MEDICAL COLLEGE, CHICAGO; PROFESSORIAL LECTURE 
DISEASES OF THE SKIN, UNIVERSITY OF CHICAGO ; DERMATOLOGIST TO THE PRESBYTERIA1 
MICHAEL REESE, AUGUSTANA, AND CHILDREN'S MEMORIAL HOSPITALS AND THE ORPHAN 
ASYLUM, OF THE CITY OF CHICAGO ; MEMBER OF THE AMERICAN DERMATOLOGICAL ASSO- 
CIATION ; CORRESPONDING MEMBER OF THE SOCIETE FRANf AISE DE DERMATOLOGIE 
ET DE SYPHILIGRAPHIE ; CORRESPONDING MEMBER OF THE WIENER DERMA- 
TOLOGISCHE GESELLSCHAFT ; AND CORRESPONDING MEMBER OF THE 
DERMATOLOGISCHE GESELLSCHAFT, AND HONORARY MEMBER 
OF THE SOCIETA ITALIANA DI DERMATOLOGIA 
E SIFILOGRAFIA 



EIGHTH AND REVISED EDITION 

ILLUSTRATED WITH 223 ENGRAVINGS AND 58 PLATES 
IN COLORS AND MONOCHROME 




LEA & FEBIGER 
PHILADELPHIA AND NEW YOEK 

1909 



A 



\ 



4^ 












Entered according to Act of Congress, in the year 1909, by 

LEA & FEBIGER 

In the Office of the Librarian of Congress, at Washington. All rights reserved 



2 4 817 6 






TO 

JAMES CIARKE WHITE, M.D. 

PROFESSOR EMERITUS OF DERMATOLOGY, HARVARD UNIVERSITY 

FIRST PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION 

AND PRESIDENT OF THE 
SIXTH INTERNATIONAL CONGRESS OF DERMATOLOGY 

THIS TREATISE IS 

WITH HIS PERMISSION INSCRIBED 



PKEFAOE TO THE EIGHTH EDITION 



The untimely death of the lamented Dr. Frank Hugh Mont- 
gomery, who was associated with the author in the production of the 
preceding three editions of this treatise, temporarily interrupted the 
work of preparation for the present revision. In this emergency the 
author acknowledges his great indebtedness to his associate, Dr. 
Oliver S. Ormsby, for valuable aid not only in the preparation of 
manuscript but also in the labor incidental to the correction of proof. 
The author desires to express also his special appreciation of the value 
of the services rendered by his colleague, Dr. E. L. McEwen, in the 
same double capacity; and to Dr. Henry G. Anthony of the Derma- 
tological Staff of the College, for correction of a part of the text. 

Every line of the last edition has been carefully revised with a 
view to improvement of the work, and it has been found necessary to 
add 250 pages in order to ensure a complete presentation of the subject 
in its latest developments. In view of their growing importance to 
practitioners of medicine, the Diseases of Warm Countries and the 
Tropics have here been considered in a separate chapter; and for 
reasons of equal weight, the affections of the Nails and the Dermatoses 
affecting the Mucous Surfaces have also been grouped together in 
separate chapters. New articles have been written on the following- 
subjects: Prurigo Nodularis, several of the special forms of Ery- 
thema, the Fourth Disease, Paraffin Prosthesis, Osteoma and Cal- 
cification of the Skin, Meralgia Paraesthetica, Acrodermatitis Pustu- 
losa Hiemalis, Lichen Spinulosus, Keratolysis Exfoliativa Congenita, 
Lipoma, Fordyce's Disease, Causalgia, Leukaemia and Pseudo- 
leukaemia Cutis, Tinea Ciliorum, and, in particular among the dis- 
orders produced by animal parasites, the important subject of Brown- 
tail Moth Dermatitis. 

The author desires also to express his grateful thanks to his der- 
matological friends in different parts of this country and abroad for 
permission to illustrate the text with portraits of interesting and rare 
dermatoses, many of which have not been heretofore published. Dr. 
John A. Fordyce, Dr. George Henry Fox, Dr. Howard Fox, and 
Dr. A. D. Mewborn, of New York; Dr. Douglass W. Montgomery 
and Dr. Howard Morrow, of San Francisco; Dr. E. E. Tyzzer of 
Cambridge, Mass.; Dr. Stopford-Taylor of Liverpool; Dr. M. L. 
Heidingsfeld of Cincinnati; and Dr. David Lieberthal and Dr. He- 
man Spalding, of Chicago, have in this way contributed largely to the 
value of the edition. In connection with the author's original collec- 
tion it has thus been possible to add 24 new plates and 120 new 
engravings. 



VI PREFACE. 

The author indulges the hope that the unstinted labor bestowed 
in the revision and improvement of this edition may increase its 
usefulness both as a text-book and as a practical work of reference. 

The reader is again reminded that in detailing the amount of 
drugs ordered in the separate prescriptions, the metric figures are not 
literal translations of the accompanying quantities given in apothe- 
caries' weight, but are frequently metric formulas of approximate 
value. 

After more than twenty-five years in association with the honored 
firm of publishers, the author takes pleasure in acknowledging his 
appreciation of their unfailing and courteous cooperation. 



CONTENTS. 



PAGE. 

Anatomy and Physiology of the Skin 17 

Physiology 51 

General Symptomatology 55 

General Etiology 08 

General Pathology 75 

General Diagnosis 81 

General Prognosis 92 

General Therapeutics 94 

Classification 133 

DISEASES OF THE SKIN. 

CLASS I. 

HYPEREMIAS AND INFLAMMATIONS. 

Erythema 135 

Erythema Hyperasrnicum 135 

Erythema Scarlatiniforme 139 

Erythema Pernio 142 

Erythema Intertrigo 143 

Erythema Multiforme 146 

Erythema Perstans 154 

Erythema Infectuosum 155 

Erytheme Miliaire Leucogenique Prurigineux Chronique 155 

Granuloma Annulare 156 

Urticaria 157 

Urticaria Pigmentosa 167 

Angioneurotic GCdema 169 

Prurigo 170 

Prurigo Nodularis 174 

Eczema 175 

Topical and Special Varieties 225 

Of Children 225 

Of the Scalp 226 

Of the Face 228 

Of the Lips 230 

Of the Nostrils 231 

Of the Ears 232 

Of the Eyelids 233 

Of the Beard 234 

Of the Genital Organs 236 

vii 



Vlll CONTENTS. 

PAGE. 

Of the Anus and Anal Region 239 

Of the Nipple and Breast of Women 241 

Of the Umbilicus 242 

Of the Legs 242 

Of the Hands and Feet 244 

Of the Nails 248 

Of the Tropics 248 

Universal 248 

Dermatitis 249 

Traumatica 249 

Venenata 250 

Caloriea 256 

I !< mgelationis 257 

Medicamentosa '.....'. 259 

Feigned Eruptions 272 

X-Ray Dermatitis 274 

Psoriasis 276 

Pityriasis Rosea 299 

Parapsoriasis 303 

Parakeratosis Variegata 303 

Dermatitis Psoriasiformis Nodularis 304 

Erythrodermie Pityriasique en Plaques Disseminees 304 

Xanthoerythrodermia Perstans 305 

Dermatitis Exfoliativa 305 

Pityriasis Rubra 308 

Dermatitis Exfoliativa Neonatorum 313 

Epidemic Exfoliative Dermatitis 314 

Primary Exfoliative Dermatitis 315 

Secondary Exfoliative Dermatitis 317 

Pityriasis Rubra Pilaris 317 

Lichen Ruber 322 

Lichen Planus 323 

Lichen Planus Annularis 332 

Lichen Planus Morphceieus 332 

Lichen Spinulosus 334 

Lichen Annularis 334 

Lichen Planus of the Mucous Surfaces 335 

Lichenification 336 

Impetigo 336 

Contagiosa 336 

Ecthyma 341 

Dermatitis Vegetans 343 

Conglomerative Pustular Perifolliculitis 344 

Folliculitis and Perifolliculitis 344 

Furunculus 345 

Carbunculus 349 

Phlegmone Diffusa 352 



CONTENTS. IX 

PAGE. 

Anthrax 352 

Equinia 355 

Dissection-wounds and Animal Poisons 357 

Erysipeloid 358 

Erysipelas 358 

Dermatitis Repens 364 

Dermatitis Gangrenosa 365 

Dermatitis Gangrenosa Infantum 367 

Symmetrical Gangrene, etc. (Raynaud's Disease) 369 

Herpes 369 

Herpes Simplex 370 

Herpes Zoster 374 

Dermatitis Herpetiformis 382 

Dermatitis Herpetiformis in Children 387 

Herpes Gestationis 387 

Hydroa Bulleux 387 

Impetigo Herpetiformis 388 

Pemphigus 390 

Acute 397 

Neonatorum 399 

Chronic 400 

Eoliaceus 402 

Vegetans 404 

Of Mucous Surfaces 406 

In Children 406 

Pompholyx 407 

Hydroa Vacciniforme 410 

Acrodermatitis Pustulosa Hiemalis 412 

Epidermolysis Bullosa Hereditaria 412 

Exanthemata 413 

Rubeola 414 

Rotheln 418 

Scarlatina 419 

Variola 424 

Varicella 435 

Vaccinia 437 

Fourth Disease (Duke's Disease) 442 

Rocky Mountain Spotted Eever 443 

CLASS II. 

HEMORRHAGES. 

Purpura -. 445 

Simplex 447 

Rheumatica 447 

Hemorrhagica 448 

Henoch's Purpura 449 



CONTENTS. 



CLASS III. 

HYPERTROPHIES. PAGE. 

Keratosis 451 

Pilaris 453 

Follieularis Spinosa 456 

Senilis 457 

Follieularis 458 

Keratodermia Palmaris et Plantaris 461 

Keratolysis Exfoliativa Congenita 466 

Mai de Meleda 467 

Porokeratosis 467 

Angiokeratoma 470 

Keratosis Follieularis Contagiosa 472 

1 1 vperkeratosis Striata et Follieularis 472 

Parakeratosis Seutularis 472 

Acanthosis Nigricans 473 

Callositas 476 

Clavus 477 

Cornu Cutaneum 479 

Verruca 481 

Synovial Lesions of the Skin 488 

Naevus Pigmentosus 489 

Linear Naevus 490 

Giant Naevus 493 

Ichthyosis 494 

Hystrix 496 

Congenita 497 

CEdema Neonatorum 501 

Sclerema Neonatorum 502 

Chronic Hereditary Trophoedoma 503 

Scleroderma 504 

Morphcea 508 

White Spot Disease 509 

Sclerodactylia 510 

Acromegaly 514 

Myxcedema 515 

CLASS IV. 

ATROPHIES. 

Atrophia Cutis 519 

Senilis 519 

Maculosa et Striata 520 

Diffuse Idiopathic 522 

Glossy Skin 522 

Blanching Atrophy of the Skin 523 



CONTENTS. xl 

PAGE. 

Multiple Benign Tumor-like New-growths 524 

Kraurosis Vulvae 52 7 ± 

Perforating Ulcer of the Foot 526 

Morvan's Disease 528 

CLASS V. 

PIGMENT ANOMALIES. 

Lentigo 531 

Anomalies of Pigmentation 532 

Leueoderma 538 

Albinismus 539 

Vitiligo 540 

CLASS VI. 

KEW-GROWTHS. 

Cicatrix 547 

Keloid 549 

Cicatricial Keloid 550 

Fibroma 554 

Simplex 556 

Dermatolysis , 557 

Paraffin Prosthesis 558 

Lipoma 561 

Adiposis Dolorosa t 562 

Neuroma 563 

Myoma 565 

Osteoma Cutis 566 

Angioma 567 

Angioma (Nsevus Vasculosus) 567 

Telangiectasis 568 

Araneus 568 

Cavernosum 568 

Serpiginosum 571 

Telangiectatic Granuloma 572 

Lymphangioma 572 

Circumscriptum 574 

Molluscum Epitheliale 576 

Xanthoma 579 

Xanthoma Diabeticorum 584 

Pseudo-Xanthoma Elasticum 586 

Colloid Metamorphosis of the Skin 586 

Calcification of the Skin 587 

Adenoma of the Sebaceous Glands 588 

Multiple Benign Cystic Epithelioma 590 

Syringocystoma 592 



Xll CONTENTS. 

PAGE. 

Xeroderma Pigmentosum 593 

Bhinoscleroma 600 

Tuberculosis Cutis 602 

1. Lupus Vulgaris 603 

2. Tuberculosis Cutis Verrucosa 609 

A. Verruca Necrogenica 609 

B. Tuberculosis Verrucosa Cutis 611 

C. Otber Verrucous Tuberculoses 611 

3. Tuberculosis Cutis Orificialis 612 

4. Scrofuloderma 613 

Tuberculosis Fuugosa Cutis 615 

Tuberculous Dactylitis 615 

Suppurative Tubercular Lymphangieetasis 615 

Tuberculosis Cutis Serpiginosa Ulcerativa 616 

Lympbangitis Tuberculosa Cutanea 616 

5. Erythema Induratum 629 

6. Dermatoses probably due to the toxines of the Bacillus Tuber- 

culosis 630 

Lichen Scrofulosorum 630 

Tuberculides 632 

Acnitis 634 

Folliclis 634 

Lupus Erythematosus 636 

Syphilis 647 

Chancre 650 

Syphilodermata 654 

Syphiloderma Maculosum 661 

Papillosum 663 

Vesiculosum 669 

Pustulosum 670 

Bullosum 674 

Tuberculosum 674 

Serpiginosum 675 

Gummatosum 679 

Erythanthema Syphiliticum 681 

Syphilis of the Mucous Surfaces 682 

Syphilodemia Infantile Acquisitum et Haereditariurn 684 

Chancroid 713 

Mycosis Fungoides 718 

Leukemia Cutis 726 

Sarcoma Cutis 728 

Melanotic Sarcoma 729 

Primary Non-pigmented Sarcoma 730 

Idiopathic Multiple Pigment-Sarcoma 731 

Sarcoid Growths 734 

Carcinoma 735 

Superficial or Discoid Epithelioma 736 



CONTENTS. Xlll 

PAGE. 

Rodent Ulcer 737 

" Craterif orm Ulcer " . . . . 738 

Paget's Disease 738 

Deep or Tubercular Epithelioma 739 

Papillary Epithelioma 740 

Cancer of the Connective Tissue 742 

Tuberose Carcinoma 744 

Melanotic Carcinoma 744 

Endothelioma 745 

Cancer of the Head 746 

Lower Lip 747 

Genital Organs 747 

Extremities 748 

Mucous Surfaces 748 

CLASS VII. 

SENSORY DERMATO-NEUROSES. 

Hypersesthesia 761 

Dermatalgia 762 

Meralgia Paresthetica 764 

Erythromelalgia 764 

Anaesthesia 766 

Paresthesia 767 

Pruritus 768 

Hiemalis 776 

Prairie Itch 779 

CLASS VIII. 

PARASITIC AFFECTIONS. 

Disorders due to Vegetable Parasites 781 

Tinea Favosa 781 

Pavus of the Nail 784 

Tinea Trichophytina 790 

Tinea Circinata 793 

Eczema Marginatum 795 

Tinea Tonsurans 796 

Tinea Sycosis 799 

Precautions in Tinea Favosa and Tinea Trichophytina 817 

Tinea Versicolor 818 

Erythrasma 823 

Blastomycosis 825 

Protozoic and Coccidioidal Infections 833 

Sporotrichosis 833 

Due to Animal Parasites 834 

Scabies 835 



XIV CONTENTS. 

PAGE. 

Deraodex Follieulormn 846 

Pules Irritans 847 

Cystieerus Cellulosae Cutis 848 

Distoma Hepaticum 849 

Leptus 849 

Belostorna £51 

Brown-tail Moth 851 

Ixodes 853 

Pediculosis 853 

Capillitii 854 

Corporis 857 

Pubis 860 

Vagabond's Disease Q 62 

Cirnex Lectularius 863 

Mosquitoes 864 

Protozoa and Sporozoa 865 

CLASS IX. 

DISORDERS OF THE APPENDAGES. 

Sweat-glands 867 

Hyperidrosis 867 

Sudamen 871 

Miliary Fever 873 

Hydroeystorna ^74 

Anidrosis S76 

Bromidrosis S77 

Chromidrosis 879 

Uridrosis 881 

Haematidrosis 882 

Hydradenitis Suppurativa 883 

Granulosis Rubra Xasi 883 

Sebaceous Glands 885 

Seborrhea 885 

Dermatitis Seborrhoica 895 

Asteatosis 904 

Milium 905 

Steatoma 907 

Congenital Fibro-sebaceous Disease 910 

Comedo 911 

Acne 916 

Acne Rosacea 930 

Acne Varioliformis 937 

The Hair and Hair Follicles 939 

Hypertrichosis 939 

Neurotica 940 

Plica Polonica 941 



CONTENTS. XV 

PAGE. 

Neuropathic Plica 941 

Atrophia Pilorum Propria 946 

Fragilitas Crinium 946 

Trichorrhexis Nodosa 947 

Monilethrix 949 

Nodose Swellings of the Shafts of the Hair 950 

Expansions and Fissures of the Hairs 950 

Lepothrix 951 

Chignon Fungus (Beigel's Disease) 952 

Tinea Nodosa 952 

Canities 952 

Alopecia 955 

Congenita 955 

Alopecia Prematura 958 

Furf uracea 960 

Senilis 961 

Areata 966 

Sycosis 976 

Folliculitis Atrophicans 984 

Keloid Acne 986 

Deciduous Hair Shedding 987 

The Nails 988 

Congenital Anomalies of the Nails 989 

Abnormal Conditions of the Nails Associated with Cutaneous Affec- 
tions 989 

Acquired Diseases of the Nails 991 

Onychauxis 994 

Morbid Conditions of the Nails induced by Cutaneous Diseases of 

the Extremities 998 

Onychomycosis 1002 

Affections of the Nails due to Syphilis 1004 

CLASS X. 

DISEASES OF THE TROPICS AND WARM COUNTRIES EXHIBITING CUTANEOUS 

LESIONS. 

Hypersemic and Inflammatory Disorders 1007 

Lichen Tropicus 1007 

Pemphigus Contagiosus 1008 

Febrile Disorders 1010 

Acrodynia 1010 

Parasitic Diseases of Animal Origin 1012 

Ankylostomiasis 1012 

Filariasis 1013 

Trypanosomiasis 1021 

Dracontiasis 1022 

Tick Fever 1025 



xvi COXTEXTS. 

PAGE. 

Chigger Disease 1026 

Myiasis 1026 

Parasitic Diseases of Vegetable Origin 1030 

Mycetoma 1030 

Actinomycosis of the Skin 1034 

Mycotic Dermatitis 1037 

Tinea Imbricata 1037 

Pinta 1039 

Piedra 1011 

Pbagedaena Tropica 1012 

Infectious Granulomata of Tropical and Warm Countries 1014 

Lepra 1014 

Tuberosa 1047 

Maculosa 1049 

Anaesthetica 1050 

Sartian Disease 1060 

Yaws 1061 

Verruga Peruana 1063 

Ulcerating Granuloma of tbe Pudenda 1065 

Oriental Sore 1066 

Bucharest Boil 1068 

Tropical Diseases of Uncertain Nature 1069 

Pellagra 1069 

Craw-craw 1072 

Cbappa 1073 

Climatic Bubo 1073 

Goundou 1074 

Ainhum 1074 

Gangosa 1076 

Veld Sore ( Xatal Sore ) 1079 

Gayle 1079 

CLASS XL 

DISEASES OF THE MUCOUS MEMBRANES IX PROXIMITY TO THE SKIX, OCCURRING 
IX ASSOCIATION WITH DERMATOSES. 

Disorders of tbe Conjunctiva and Eyelids 1081 

Demodex Folliculorum 1081 

Tricbiasis 1081 

" Eczematous Conjunctivitis " 1081 

The Exanthemata 1082 

Acne Rosacea 1082 

Pemphigus 1082 

Lupus Vulgaris 1082 

Epithelioma 1082 

Hydroa Puerorum 1082 

Herpes Simplex and Herpes Zoster 1083 



CONTENTS. XV u 

PAGE. 

Zoster Ophthalmicus 1083 

Other Diseases 1083 

Lepra 1083 

Blastomycosis 1083 

Disorders of the External Auditory Meatus 1084 

Furuncles of the External Auditory Meatus 1084 

Syphilitic Lesions 1084 

Otomycosis 1084 

Disorders of the Nasal Cavities 1084 

Syphilis 1084 

Tuberculosis 1085 

Rhinoscleroma 1085 

Glanders 1085 

Lepra 1085 

Disorders of the Mucous Membrane of the Mouth 1086 

Fordyce's Disease 1086 

Perleche 1086 

Cheilitis 1087 

Glandularis 1088 

Bael's Disease 1088 

Leucokeratosis Bucealis 1088 

Variola 1091 

Vaccinia 1092 

Scarlatina 1092 

Measles 1092 

Erythema Multiforme 1092 

Psoriasis 1092 

Pseudo Herpes Bucealis 1093 

Angioneurotic CEdema and Urticaria 1093 

Leukaemia 1093 

Xanthoma 1093 

Adenonia Sebaceum 1094 

Lupus Vulgaris 1094 

Lichen Planus 1094 

Lupus Erythematosus 1094 

Syphilis 1095 

Actinomycosis of Mucous Membranes 1095 

Precancerous Keratosis of the Mucous Surfaces of the Mouth 1095 

Cancer 1096 

Scurvy 1096 

Blastomycosis 1097 

Lepra 1097 

Disorders of the Vulva and Vagina 1098 

Syphilis 1098 

Chancroid 1098 

Verruca Acuminata 1098 

Pruritus Vulva? 1098 



[i CONTENTS. 

PAGE. 

Inflammations of the Vulva 1098 

Tuberculosis Cutis Orificialis 1099 

Dermoid and Sebaceous Cysts 1099 

Urethral Caruncles 1099 

Lichen Planus 1°99 

Pemphigus Vegetans 1099 

Elephantiasis 1099 

Carcinoma 1099 

Kraurosis Vulva? 1099 



LIST OF ILLUSTRATIONS. 



FIG. PAGE. 

1. Section of skin from palm of the hand 18 

2. Subcutaneous fat-tissue 20 

3. Columnar adiposas 22 

4. Vertical section of skin after injection (from beneath) with Berlin 

blue 23 

5. Vascular and nervous papillae 24 

6. Scalp of a negro — horizontal section 26 

7. Prickle-cells 27 

8. Pacinian body, after silver staining 33 

9. Section of a papilla containing a tactile body (from the skin of a 

finger) 34 

10. Transverse section of nervous papilla 35 

11. Section of a hair-follicle during the formation of a new hair 39 

12. Hair-follicle in longitudinal section 39 

13. Lower portion of a hair-pouch from the lip of a kitten 41 

14. Transverse section of hair and follicle 42 

15. 16. Sebaceous glands of the second class, from the ake of the nose 44 

17. Coil of a sweat-gland 45 

18. Sweat-pore traversing the epithelial layers of the skin 46 

19. Section of skin from the palm of the hand 47 

20. Vertical section of one-half of nail and matrix 49 

21. Implantation of a nail at its border 50 

22. Irido-platinum needle 122 

23. Milium needle 122 

24. Scarifying-spud .' 122 

25. Epilating-forceps 122 

26. Piffard's grappling-forceps 122 

27. Piffard's cutisector 123 

28. 29. Dermal curettes 123 

30. Hess's pleximeter 123 

31. Comedo-extractor 123 

32. Cutaneous punch 123 

33. Massering-ball 123 

34. Toxic erythema 138 

35. Erythema multiforme 146 

36. Erythema multiforme 147 

37. Erythema multiforme 149 

38. Dermographism .' ' 158 

39. Urticaria pigmentosa 168 

40. Eczema nuchas 180 

41. Eczema pustulosum 182 

xix 



XX LIST OF ILLUSTEATIONS. 

FIG. PAGE. 

42. Eczema impetiginosum 183 

43. Eczema pustulosum 184 

44. Eczema orbiculare 187 

45. Eczema of the legs 243 

46. Eczema fissum 245 

47. Dermatitis venenata 250 

48. Dermatitis venenata 251 

49. Dermatitis venenata produced by chemicals 252 

50. Rhus radicans 253 

51. Arsenical pigmentation and keratosis 261 

52. Papilloma, due to the ingestion of the iodine compounds 265 

53. Dermatitis medicamentosa 266 

54. Radio-dermatitis, third degree, upon keratodermia 275 

55. Psoriasis, generalized and in large plaques 277 

56. Psoriasis (large plaques) 278 

57. Primary exfoliative dermatitis 316 

58. Pityriasis rubra pilaris 318 

59. Lichen planus 323 

60. Lichen planus 324 

61. Lichen ruber moniliformis 326 

62. Lichen planus atrophicus . . . 333 

63. Staphylococcia 337 

64. Impetigo contagiosa 338 

65. Malignant pustule bacilli and pus-corpuscles 354 

66. Dermatitis gangrenosa infantum 367 

67. Dermatitis gangrenosa infantum 368 

68. Acute pemphigus 398 

69. Dysidrosis 408 

70. Vertical section of pustule at the beginning of pustulation 426 

71. Vertical section of one-half of an undeveloped variola-pustule .... 428 

72. Keratodermia palmaris et plantaris hereditaria 462 

73. Porokeratosis 46S 

74. Acanthosis nigricans 474 

75. Acanthosis nigricans 475 

76. Acanthosis nigricans 475 

77. 78. Cutaneous horns 480 

79. Cornu cutaneum 481 

SO. Verruca juvenilis plana 4S4 

81. Vertical section of summit of pointed wart 486 

82. Nsevus pilaris et pigmentosus 490 

83. Nsevus linearis 491 

84. Nsevus pigmentosus 492 

85. Nsevus unius lateralis 493 

86. Ichthyosis hystrix 495 

87. Ichthyosis hystrix, vertical section 496 

SS. Chronic hereditary trophoedema 503 

89. Generalized scleroderma 505 



LIST OF ILLUSTBATIONS. XXI 

FIG. PAGE. 

90. Scleroderma occurring in patient with morplicea guttata 506 

91. Morphcea guttata 507 

92. Vitiligo 541 

93. Vitiligo 542 

94. Vitiligo 543 

95. Vitiligo 544 

96. Keloid 550 

97. Hypertrophic scars (Keloid) 551 

98. Hypertrophic scars (Keloid) 552 

99. Paraffin prosthesis 558 

100. Section from tumor induced by paraffin 559 

101. Section same as Fig. 100 560 

102. Lipomata 561 

103. Neuroma of the skin 563 

104. Microscopic structure of neuroma 564 

105. Lymphangiectodes 575 

106. Molluscous corpuscles 578 

107. Adenoma sebaceum 589 

108. Xeroderma pigmentosum 594 

109. Xeroderma pigmentosum 595 

110. Lupus vulgaris 603 

111. Lupus vulgaris 604 

112. Lupus vulgaris in a colored patient 605 

113. Lupus vulgaris serpiginosus 606 

114. Tuberculosis verrucosa cutis 610 

115. Scrofuloderma 614 

116. Generalized tuberculide 633 

117. Lupus erythematosus of the face 637 

118. Lupus erythematosus (seborrhoie type) 638 

119. Initial sclerosis of syphilis (extragenital chancre) 651 

120. Facial cicatrices of tubercular syphilodermata after twenty-five 

years of infection 657 

121. Alopecia syphilitica 660 

122. Small flat papular syphiloderm 666 

123. Vegetating condylomata of the vulva and anus 667 

124. Corymbose papular syphilide 668 

125. Ulcerative tubercular syphiloderm 675 

126. Gummatous syphiloderm 676 

127. Tubercular sphiloderm 677 

128. Syphiloma of the vulva with gummatous changes in labia and clitoris 678 

129. Mycosis fungoides 721 

130. Mycosis fungoides 722 

131. Multiple hemorrhagic sarcoma 731 

132. Sarcoma 733 

133. Rodent ulcer 736 

134. Paget's disease of the breast 739 

135. Epithelioma of the forehead 740 



XX LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

42. Eczema impetiginosum 183 

43. Eczema pustulosum 184 

44. Eczema orbiculare 187 

45. Eczema of the legs 243 

46. Eczema fissum 245 

47. Dermatitis venenata 250 

48. Dermatitis venenata 251 

49. Dermatitis venenata produced by chemicals 252 

50. Rhus radicans 253 

51. Arsenical pigmentation and keratosis 261 

52. Papilloma, due to the ingestion of the iodine compounds 265 

53. Dermatitis medicamentosa 266 

54. Radio-dermatitis, third degree, upon keratodermia 275 

55. Psoriasis, generalized and in large plaques 277 

56. Psoriasis (large plaques) 278 

57. Primary exfoliative dermatitis 316 

58. Pityriasis rubra pilaris 318 

59. Lichen planus 323 

60. Lichen planus 324 

61. Lichen ruber monilif oi'inis 326 

62. Lichen planus atrophicus 333 

63. Staphylococcia 337 

64. Impetigo contagiosa 338 

65. Malignant pustule bacilli and pus-corpuscles 354 

66. Dermatitis gangrenosa infantum 367 

67. Dermatitis gangrenosa infantum 368 

68. Acute pemphigus 398 

69. Dysidrosis 408 

70. Vertical section of pustule at the beginning of pustulation 426 

71. Vertical section of one-half of an undeveloped variola-pustule .... 428 

72. Keratodermia palmaris et plantaris hereditaria 462 

73. Porokeratosis 468 

74. Acanthosis nigricans 474 

75. Acanthosis nigricans 475 

76. Acanthosis nigricans 475 

77. 78. Cutaneous horns 480 

79. Cornu cutaneum 481 

80. Verruca juvenilis plana 484 

81. Vertical section of summit of pointed wart 486 

82. Nevus pilaris et pigmentosus 490 

83. Nevus linearis 491 

84. Nevus pigmentosus 492 

85. Nevus unius lateralis 493 

86. Ichthyosis hystrix 495 

87. Ichthyosis hystrix, vertical section 496 

S8. Chronic hereditary trophedema 503 

89. Generalized scleroderma 505 



LIST OF ILLUSTRATIONS. XXI 

FIG. PAGE. 

90. Scleroderma occurring in patient with niorphoea guttata 506 

91. Morphcea guttata 507 

92. Vitiligo 541 

93. Vitiligo 542 

94. Vitiligo 543 

95. Vitiligo 544 

96. Keloid 550 

97. Hypertrophic scars (Keloid) 551 

98. Hypertrophic scars (Keloid) 552 

99. Paraffin prosthesis 558 

100. Section from tumor induced by paraffin 559 

101. Section same as Fig. 100 560 

102. Lipomata 561 

103. Neuroma of the skin 563 

104. Microscopic structure of neuroma 564 

105. Lymphangiectodes 575 

106. Molluscous corpuscles 578 

107. Adenoma sebaceum 589 

108. Xeroderma pigmentosum 594 

109. Xeroderma pigmentosum 595 

110. Lupus vulgaris 603 

111. Lupus vulgaris 604 

112. Lupus vulgaris in a colored patient 605 

113. Lupus vulgaris serpiginosus 606 

114. Tuberculosis verrucosa cutis 610 

115. Scrofuloderma 614 

116. Generalized tuberculide 633 

117. Lupus erythematosus of the face 637 

118. Lupus erythematosus (seborrhoic type) 638 

119. Initial sclerosis of syphilis (extragenital chancre) 651 

120. Facial cicatrices of tubercular syphilodermata after twenty-five 

years of infection . . 657 

121. Alopecia syphilitica 660 

122. Small flat papular syphiloderm 666 

123. Vegetating condylomata of the vulva and anus. 667 

124. Corymbose papular syphilide 668 

125. Ulcerative tubercular syphiloderm 675 

126. Gummatous syphiloderm 676 

127. Tubercular sphiloderm 677 

128. Syphiloma of the vulva with gummatous changes in labia and clitoris 678 

129. Mycosis fungoides 721 

130. Mycosis fungoides 722 

131. Multiple hemorrhagic sarcoma 731 

132. Sarcoma 733 

133. Rodent ulcer 736 

134. Paget's disease of the breast 739 

135. Epithelioma of the forehead 740 



xxii LIST OF ILLUSTRATIONS. 

FIG. PAGE. 

136. Carcinoma developing upon lupus vulgaris 741 

137. Cancer en cuirasse 712 

138. Cancer en cuirasse 713 

139. Carcinoma and pre-eaneerous keratoses 747 

140. Relapsing rodent ulcer in scar tissue 749 

141. Paget's disease of the buttock 750 

142. Cancer of the leg, of the prickle, or squamous-cell type 75] 

143. Epithelioma of the basal-cell type 752 

144. Cylindroma of the scalp 753 

145. Carcinoma of the ear 754 

146. Epithelioma 755 

147. Carcinoma of the lip 756 

14S. Epithelioma of the ear 756 

149. Carcinoma of the lip 757 

150. Epithelioma of the cheek 75S 

151. Favus capitis 7S2 

152. Culture of achorion of Schoenlein 7S4 

153. Achorion Schoenleinii 785 

154. Trichophytosis corporis 794 

155. Trichophytosis capitis 796 

156. Tinea sycosis 800 

157. Tinea sycosis 801 

158. Filaments and spores of trichophyton from the beard 803 

159. Epidermis invaded by trichophyton 801 

160. Hair invaded by the trichophyton 805 

161. Trichophyton endothrix culture from the scalp 805 

162. Culture three weeks old from ringworm S06 

163. Trichophyton ectothrix culture 806 

164. Trichophyton ectothrix culture 807 

165. Chromophytosis guttata 819 

166. Microsporon furfur 820 

167. Microsporon minutissimum 823 

168. Female aearus 836 

169. Acarian furrow 837 

170. Demodex folliculorum 846 

171. Leptus Americanus 819 

172. Leptus 850 

173. Rou-et 850 

174. Section showing inflammatory changes in coriuin twenty-four hours 

after the skin had been rubbed lightly with a small brown-tail 

caterpillar 851 

175. Section of caterpillar 853 

176. Sketch showing effect of the nettling hairs of the brown-tail moth 

upon mammalian red-blood corpuscles 852 

177. Ova of head-louse attached to hair 855 

178. Pediculus capillitii £35 

179. Pediculus corporis 857 



LIST OF ILLUSTRATIONS. XXlll 

FIG. PAGE. 

ISO. Pediculus pubis 861 

181. Hydrocystoma S74 

182. Dermatitis seborrboica 897 

183. Dermatitis seborrboica SOS 

184. Multiple sebaceous cysts of tbe scrotum 910 

185. Section of a comedo 913 

186. Acne vulgaris 918 

187. Scars following acne vulgaris 919 

188. Rbynopbyma 936 

189. Acne necrotica 937 

190. Tbe Russian " dog-faced man " 939 

191. Congenital atropby of bair 946 

192. Trichorrhexis nodosa 948 

193. Trichorrhexis moniliformis 949 

194. Trichorrhexis nodosa 950 

195. Alopecia congenita 956 

196. Alopecia areata 966 

197. Alopecia areata 967 

198. 199. Alopecia areata 96S 

200. Sycosis vulgaris 977 

201. Lupoid sycosis 979 

202. Onychogrypbosis in a leper 990 

203. Onychogrypbosis 991 

204. Tinea trichophytina unguis 1002 

205. Onychia and paronychia occurring in conjunction with a gener- 

alized pustular sypbiloderm 1005 

206. Elephantiasis scroti 1015 

207. Elephantiasis of the foot and leg 1016 

208. CEstrus 1027 

209. Larvae from body of child 1027 

210. Osseous lesions in mycetoma 1032 

211. Leprosy 1045 

212. Leproma of ocular globe 1046 

213. Leprosy 1047 

214. Anaesthetic leprosy 1051 

215. Larynx of patient affected with lepra tuberosa 1055 

216. Bacilli of leprosy 1056 

217. Acute pellagra 1070 

218. Gangosa 1077 

219. 220. Gangosa 1078 

221. Lichen planus of mucous surface of the tongue 1094 

222. Chancre of the lip 1096 

223. Blastomycosis of tbe lip 1097 



LIST OF PLATES. 



Plate 


I. 


Plate 


II. 


Plate 


III. 


Plate 


IV. 


Plate 


V. 


Plate 


VI. 


Plate 


VII. 


Plate 


VIII. 


Plate 


IX. 


Plate 


X. 


Plate 


XL 


Plate 


XII. 


Plate 


XIII. 


Plate 


XIV. 


Plate 


XV. 


Plate 


XVI. 


Plate 


XVII. 


Plate 


XVIII. 


Plate 


XIX. 


Plate 


XX. 


Plate 


XXI. 


Plate 


XXII. 


Plate 


XXIII. 


Plate 


XXIV. 


Plate 


XXV. 


Plate 


XXVI. 


Plate 


XXVII. 


Plate 


XXVIII. 


Plate 


XXIX. 


Plate 


XXX. 


Plate 


XXXI. 


Plate 


XXXII. 


Plate 


XXXIII. 


Plate 


XXXIV. 


Plate 


XXXV. 


Plate 


XXXVI. 


Plate 


XXXVII. 



Xeroderma Pigmentosum Frontispiece 

Erythema Multiforme. Circinate Type . . facing page 150 
Traumatic Dermatitis consecutive to pru- 
ritus cutaneus facing page 249 

Dermatitis Factitia facing page 272 

Generalized Psoriasis facing page 280 

Pityriasis Rosea facing page 299 

Erythrodermie Pityriasique facing page 304 

Pityriasis Rubra Pilaris facing page 320 

Cutaneous Lesions in Equinia facing page 356 

Dermatitis Herpetiformis facing page 384 

Chronic Pemphigus facing page 400 

Variola facing page 424 

Variola facing page 425 

Variola facing page 429 

Variola facing page 430 

Variola facing page 431 

Purpura Due to Copaiba facing page 446 

Keratosis Punctata in a man who had 
been taking arsenic for a long stand- 
ing Psoriasis facing page 461 

Palmar Keratosis, due to Arsenic facing page 464 

Congenital Warts facing page 482 

Nsevus Lipomatodes facing page 489 

Morphoea facing page 508 

Malum Perforans Pedis, with Symmet- 
rical Keratoma of the Palms and Soles, facing page 526 

Keloid in the Negro facing page 549 

Multiple Fibroma of the Back facing page 554 

Fibroma Pendulum facing page 555 

Xanthoma facing page 579 

Xanthoma Tuberosum of Hands facing page 580 

Xanthoma Multiplex facing page 581 

Xanthoma Diabeticorum facing page 584 

Syringocystoma facing page 592 

Lupus Hypertrophicus facing page 607 

Miliary Papular Syphiloderm facing page 663 

Flat Papular Syphiloderm facing page 664 

Flat Papular Syphiloderm facing page 665 

Annular Papular Syphiloderm facing page 666 

Large Flat Pustular Syphiloderm facing page 672 

XXV 



LIST OF PLATES. 



Plate XXXVIII. 



Plate XXXIX. 



Plate 


XL. 


Plate 


XLI. 


Plate 


XLII. 


Plate 


XLIII. 



Plate 



Plate 
Plate 



Plate 
Plate 

Plate 



XL1V 



XLV. 
XLVI. 



Plate XL VII. 



XLVIII. 
XLIX. 



Plate 


LI. 


Plate 


LII. 


Plate 


Lin. 


Plate 


LIV 


Plate 


LV. 


Plate 


LVI. 


Plate 


LVII. 


Plate 


LVIII. 



Large Pustulo-crustaceous Syphiloderm 

of the scalp and body facing page 673 

Tubercular Syphiloderm, Resolutive and 

Serpiginous facing page 674 

Prefungoid Stage of Mycosis Fungoides. facing page 718 

Mycosis Fungoides facing page 724 

Multiple Pigmented Idiopathic Sarcoma facing page 732 
Clinical Varieties of Cutaneous Carci- 
noma facing page 735 

Multiple Carcinomata, with Diffuse Pre- 
cancerous Hyperkeratosis facing page 740 

Favus Corporis facing page 782 

Favus Corporis. Generalized Distribu- 
tion facing page 7S3 

Mierosporon Audouini and Megalosporon 

Endothrix X 500 facing page 804 

Blastomycosis facing page 825 

Clinical Types of Cutaneous Blastomy- 
cosis facing page 827 

Histological and Bacteriological Features 

of Blastomycosis facing page 829 

Dermatitis Seborrhoi'ca facing page 900 

Dermatitis Seborrhoi'ca facing page 901 

Acne-keloid of the Back facing page 920 

Syphilis of the Nails facing page 1004 

Elephantiasis Telangiectodes of the 

Upper Lip and Portions of the Face. facing page 1013 

Mycetoma of the Foot -.facing page 1030 

Fordyce's Disease facing page 1086 

Leucokeratosis Buccalis facing page 1089> 



ABBREVIATIONS EMPLOYED IN 
THE WORK. 



Annales: Annales de Dermatologie et de Syphiligraphie, Paris. 

Arehiv: Archiv fiir Dermatologie und Syphilis, 1869-73; and since 1889. 

B. J. D. : British Journal of Dermatology, London. 

Centralb. : Dermatologisches Centralblatt, Leipzig. 

Giorn. ital. : Giornale italiano delle malattie veneree e della pelle, Milan. 

J. C. D. : Journal of Cutaneous and Venereal Diseases, 1882-87; Journal of 
Cutaneous and Genito-Urinary Diseases, 1888-1902 ; Journal of Cutaneous Diseases, 
including Syphilis, since 1903, New York. 

Jour. mal. cutan. : Journal des maladies cutanees et syphilitiques, Paris. 

Monatshefte: Monatshefte fiir praktische Dermatologie, Hamburg. 

Vierteljahr. : Viertejahresschrift fiir Dermatologie und Syphilis, 1874-88. 

Zeitschrift: Dermatologische Zeitschrift, Berlin. 

Brit. Med. Jour.: British Medical Journal, London. 

J. A. M. A.: Journal of the American Medical Association, Chicago. 

Allbutt's System: A System of Medicine by Many Writers, edited by T. C. 
Allbutt, New York, 1901. 

American Text-book: An American Text-book of Genito-Urinary Diseases, 
Syphilis, and Diseases of the Skin, edited by L. Bolton Bangs and W. A. Hardaway, 
Philadelphia. 

Besnier's and Doyon's Notes: Besnier's and Doyon's notes in their French 
translation of Kaposi's treatise. 

Crocker, Diseases of the Skin : Diseases of the Skin, by Radcliff e Crocker, third 
edition, Philadelphia, 1903. 

Duhring, Cutaneous Medicine: Cutaneous Medicine, Parts I. and II., by Louis 
Duhring, Philadelphia, 1896. 

Internat. Atlas: The International Atlas of Pare Diseases of the Skin. 

Jarisch, Die Hautkrankheiten : Die Hautkrankheiten, Nothnagel 's Specielle 
Pathologie und Therapie XXIV., Vienna, 1900 u. 1901. 

Kaposi, Diseases of the Skin: Pathologie und Therapie der Hautkrankheiten, 
ninth edition, 1899. 

La Pratique Dermatologique : La Pratique Dermatologique, Traite de Derma- 
tologie appliquee, edited by E. Besnier, L. Brocq, and L. Jacquet, Paris, 1900-1902. 

MacLeod Pathology: Practical Handbook of the Pathology of the Skin, by 
J. M. H. MacLeod, London and Phila., 1903. 

Manson, Tropical Diseases, by Sir Patrick Manson, London, 1900. 

Morrow's System: A System of the Genito-Urinary Diseases, Syphilology, and 
Dermatology, edited by Prince A. Morrow, New York, 1894. 

Mrae,ek, Handbuch: Handbuch der Hautkrankheiten, edited by Franz Mra§ek, 
Vienna, 1901-1903. 

Scheube, Diseases of Warm Countries: Diseases of Warm Countries, by B. 
Scheube, translated by Pauline Falcke, edited by James Cantlie, Phila., 1903. 

Stelwagon, Diseases of the Skin: Treatise on Diseases of the Skin, Henry W. 
Stelwagon, Phila. and London, 1907. 

Twentieth Century Practice: Twentieth Century Practice of Medicine, edited 
by Thomas L. Stedman, New York, 1896. 

Unna, Histopathology : The Histopathology of the Skin, P. G. Unna; English 
translation by Norman Walker, Edinburgh and New York, 1896. 



I. ANATOMY AND PHYSIOLOGY OF 
THE SKIN. 



The skin is the living envelope of the human body ; it is closely 
associated with underlying structures, and by its situation is brought 
into intimate relation also with the external world. The skin is a 
complex, elastic, and sensitive organ, varying greatly in different con- 
ditions of climate, age, sex, health, and race ; and varying also in the 
characteristics exhibited in different localities upon the same indi- 
vidual. Thus, in color there is a wide range between the fair skin of 
the blonde and the black skin of the negro, between the rosy pink of 
the infant's palm and the dark-brown hue of the genital region of the 
aged. The skin varies also in pliability and thickness, being delicate 
and lax over the eyelids, the lips, and the prepuce ; and much thicker 
and more firmly attached over the palms and the soles. 

The appearance of the skin, even in conditions of health, changes 
within appreciable limits. It is the exposed parts (such as the face) 
which the eye of the physician most frequently searches, and which 
betray evidence of mental emotions, physiological fluxes, sedentary or 
active habits of life, and fatigue or unusual conditions of vigor. 

Ridges and Furrows. — Viewed externally, the skin is seen to be 
traversed by superficial and deeper furrows, which vary in arrange- 
ment and size according to their situation. They are formed by the 
attachment of the skin to the deeper structures, by the movements to 
which the part is subjected, and by the arrangement of the fibrous 
structures of the corium. In some situations (palms and soles) the 
fine furrows have a regular arrangement and run parallel with each 
other. The pattern thus outlined is constant in the individual, of 
which fact use is made in the identification of criminals. Between 
these fine furrows are ridges dotted with numerous depressions repre- 
senting the openings of sweat-pores. The entire body is traversed by 
fine furrows which form an irregularly diamond-shaped network. 

Coarse furrows are found chiefly in situations where the skin is 
subjected to movement, such as about the joints, and they are due to 
the fixation of the skin to deeper structures by fibrous bundles. It is 
in such situations that fissures occur when the normal pliability is lost 

1 For further details regarding the anatomy and physiology of the skin, the 
reader is referred to Duhring, Cutaneous Medicine, vol. i., pp. 1-71 (bibliography) ; 
Eabl and Kreidl, Mracek, Handbuch, Bd. i., pp. 1-266 (complete bibliography) ; 
Darier, La Pratique Dermatologique, t. i., pp. 7-59; Unna (translation by "W. T. 
Alexander), Ziemssen's Handbook of Skin Disease, pp. 1-66; Besnier, Brocq, et 
Jaequet, La Pratique Derm, t. i., p. 7, Paris, 1900; Poirier et Chospy, Traite 
d 'Anatom. Hum., Paris, 1904, v. 5. 

2 17 



18 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



Fig. 1. 




Section of skin from the palm of the hand, magnified 150 diameters ; a, stratum 
corneum ; a', its superficial layer ; b, stratum lucidum ; c, stratum granulosum ; d, 
stratum mucosum (rete) ; e, pars papillaris of the corium, loops of capillary vessels 
showing in vascular papillae ; f, pars reticularis of the corium, showing coarse inter- 
lacing connective-tissue bundles ; g, transverse section of the latter ; h, double-contoured 
nerve-fibres passing to tactile body ; i, coil-glands : k, ducts of coil-glands ; 1, sweat- 
pores passing to surface of the epidermis ; m, arteries of the skin terminating in capil- 
laries ; n, veins of the skin forming plexuses ; o, fat-cells, encompassed by capillary 
loops, in relation with coil-glands (the capillaries of the latter are purposely omitted in 
the drawing) ; p, obliquely and transversely divided bundles of connective-tissue fibres 
of the corium and subcutaneous tissue. 



ANATOMY. 19 

through inflammatory thickening. The shape of many of the lesions 
of the skin is determined by the ridges and furrows above described. 

The digital extremities are protected by the nails, and the skin is 
provided very generally with coarse or with fine, downy hairs, which 
in some parts are of sufficient growth to conceal the skin from view. 
This pilary growth serves not merely as an ornament of the body, but 
also as a protection to some of its regions most sensitive to thermal 
changes. 

Development of the Skin. 1 — The corium is developed in intra- 
uterine life from the superficial layer of the mesoblast (the " skin- 
plate " of Bemak). Its lower portions become first visible in a myxo- 
fibrous structure, which between the seventh and eighth months is 
replaced by a collagenous substance, from which the bundles of con- 
nective tissue develop, finer fibrillse becoming later elastic fibres. 

The epidermis springs from the ectoderm, and has therefore no 
primary histological relation with the corium, though at about the 
fourth month it is projected upon the papillary layer so as to give rise 
to the grooves and interdigitations which produce in the skin of the 
adult an important and intimate connection between the two. 2 At 
first a single layer, later two, three, and more rows of prickle-cells 
develop up to the fifth month, the horny covering persisting up to the 
seventh month merely as a thin stratum composed of but two rows of 
cells. The appendages of the skin are mostly developed between the 
sixth and eighth months. 

Epitrichial Layer. — Welcher, 3 Minot, 4 and Bowen 5 have described 
a layer of large cells, with round nuclei much larger than those of the 
epidermal layers beneath, covering the entire body of the human 
embryo during the early months of its existence. This layer, his- 
tologically, is quite distinct from the outer cells of the stratum cor- 
neum, and corresponds with the epitrichium of certain animals. It 
usually disappears before the sixth or seventh month of intrauterine 
life. 

The integument of the body, when studied with the aid of the mi- 
croscope, is found to be composed of several organic parts, which are : 
the subcutaneous connective tissue (the hypoderm), resting on the 
deeper structures of the body ; then, more externally, the corium, or 
true skin ; lastly, an outermost coat, the epidermis, or cuticle. Beside 

1 For detailed description, with illustrations, see MacLeod, Brit. Jour. Derm., 
1898, x., pp. 183 and 221. 

2 The researches of Leo Loeb (Archiv. f. Entwicklungsmechanik d. organ., 1897, 
vi., p. 1), and of Alexander Maximow ("Experimentelle Untersuchungen iiber die 
Entziindliche Neubildung von Bindegewebe, " Ziegler's Beitrage, Suppl. v.) show, 
however, that cells indistinguishable from epithelial cells may develop from the 
mesoderm. Kromayer (Archiv, 1902, lxii., p. 299) states that connective tissue may 
originate in epithelial cells, and he believes the corium is derived from the basal 
layer of the rete. He has, however, few supporters in these views. Cf. MacLeod, 
Brit. Jour. Derm., 1903/ xv., p. 257. 

3 Tiber die Entwickelung bei Bradypus, Halle, 1854. 

4 Amer. Naturalist, June, 1886. 

5 Anatomischen Anzieger, iv. Jahrgang (1889), Nr. 13 u. 14; and Jour. Cutan. 
Dis., 1895, xiii., p. 485. 



20 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



these parts, the skin contains coil-glands, sebaceous glands, hairs, 
nails, blood-vessels, lymph-vessels, muscles, pigment, and nerves. It 
will be instructive to study the deeper parts of the skin before con- 
sidering those more superficially disposed, as their mutual relations 
will thus be made clearer. 



SUBCUTANEOUS TISSUE (STRATUM SUBCUTANEUM, 
NICULUS ADIPOSUS). 



PAN- 



The subcutaneous tissue, or hypoderm, is differentiated from the 
corium between the third and the fourth months of foetal life. It is a 
structure serving a mechanical purpose as a receptacle for fat, and for 
the support of vessels and nerves passing from the tissue beneath to 
the corium which lies next above it. It contains, also, coil-glands, 
some of the hair-follicles more deeply seated than their fellows, and 
Pacinian corpuscles. There is no distinct boundary-line between the 
upper limits of the subcutaneous tissue and the overlying corium, to 
which it projects columnar masses of fat, extending obliquely to the 

coil-glands and the hair-follicles 
• above, often with lateral, horizon- 

: ^%f}^-=-'^IS^jr^^fc^ tally disposed prolongations of 
lii - ' «/!»'' r **s similar shape. It is built up of 

loose connective-tissue bundles, 
prolonged from the aponeuroses, 
fasciae, and the membranes lying 
beneath. 

The subcutaneous tissue is at- 
tached firmly to the skin over 
the extensor surfaces of the ar- 
ticulations, the palms and soles, 
and the groins by short, coarse 
bundles, between which are single 
or multil ocular spaces lined with 
endothelia secreting a mucoid 
fluid. Some of these are congen- 
ital ; others result from evolution 
later in life. They are most fre- 
quent and largest where necessary 
movements occur, as where the 
skin is stretched over bone or ten- 
don. These spaces are the Bur see 
Mucosae. Elsewhere as in the 
eyelids, the penis, the scrotum, 
and the auricle of the ear, the attachment to the skin is by loose, 
delicate connective tissue containing no fat-globules. All other 
fibrous tracts are arranged obliquely ; they admit, by their extension, 
of various degrees of pliability, and inclose rhomboidal spaces con- 
taining more or less numerous fat-globules. These spaces are lobu- 




Subcutaneous fat-tissue, the fat hav- 
ing been extracted with turpentine : B, 
bundles of fibrous connective tissue, car- 
rying injected blood-vessels ; C, capsules of 
fat-globules, with oblong nuclei. Magni- 
fied 500 diameters., (After Hbitzmann.) 



THE TBUE SKIN. 21 

lated, are bounded by a delicate fibrous connective tissue, and are sup- 
plied abundantly with blood-vessels. 

The deposit of fat in the body is reduced greatly in all diseases 
productive of emaciation, but never wholly disappears during life. 
In cases of obesity, fat is deposited in excess of normal limits, and it 
may then be concerned in the production or the aggravation of dis- 
ease. It is due largely to the greater or lesser volume of the pannicu- 
lus adiposus that the natural outlines of the body are made to the eye 
graceful and attractive, or the reverse. 

Columnae Adiposse (Fat-columns of Warren). — The credit of 
discovering and naming the Fat-columns belongs to Warren, whose 
studies were principally directed to the anatomy of the thick cutis 
vera. 1 The back and shoulders of a vigorous adult furnish an integu- 
ment much thicker than the hide of many pachydermatous animals. 
The papillae are imperfectly formed and are represented by an undu- 
lating line. The follicles of the lanugo-hairs penetrate only the super- 
ficial layers of the cutis. From the bases of the hair-follicles nearly 
vertical clefts, or slender, columnar-shaped spaces, extend obliquely 
to the panniculus adiposus. These shafts are named " fat-columns " 
or " fat-canals," as they are entirely occupied by adipose tissue. (See 
Figs. 3 and 4.) 

The fat-columns are about four millimetres in length, and slightly 
wider than the hair-follicles above. Their long axes form a slight 
angle with that of the follicle, but they are nearly parallel with that of 
the erector pili muscle. The horizontal prolongations are given off on 
either side of the middle of this axis, partly fat-filled. Near this 
point the coil of a sweat-gland is seen to be held in place by a few 
delicate fibres. The duct of the gland runs to the top of this space, 
whence it may be traced to the side of the hair-follicle. The connec- 
tive-tissue fibres seem to terminate abruptly at the edges of these 
columns. The cleft slightly widens below, and on the side toward 
which its axis leans the fibres of connective tissue form a bundle pene- 
trating below to the subcutaneous fat. The erector pili muscle is in- 
serted partly into the base of the follicle and partly into the apex of 
the fat-canal. These columns correspond in number with that of the 
hairs. The blood-vessels they contain, which spring from the sub- 
cutaneous plexus, bifurcate at the lateral clefts. Unna demonstrates 
that the fat-columns invariably advance toward the coil-glands either 
singly or in groups, and that the connection of the fat-columns with 
the hair-follicles is a mere incident of that advance. 

THE CORIUM, DERMA, CUTIS, CUTIS VERA, OR TRUE SKIN. 

The corium is a mesoblastic structure made up largely of con- 
nective tissue and cellular elements. It is rich in blood-vessels and 
capillaries, especially in the papillary layer, and contains many 
nerves, nerve-endings, and terminal nerve organs. It also contains 
1 Satterthwaite 's Manual of Histology, p. 420. New York, 1881. 



22 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

lymphatics, small muscle-fibres, hairs, sweat-glands, and sebaceous 
glands. 

The fibrous elements are of two varieties, collagen and elastin. 
The collagen occurs as bundles of fibres held together by a semi- 
fluid, interfibrillary substance, which stains brown with silver nitrate. 
The fibres are about H200 of an inch (.79/*) in breadth and, according 
to Clarkson, 1 are made up of fibrils that are approximately %oooo to 
/4oooo of an inch (.05/* to .12/*) thick. The collagenous bundles are 
only slightly extensible, but as their arrangement presents a wavy 

Fig. 3. 




Vertical section of the skin showing : a, epidermis ; b, erector pili muscle ; d, 
columnse adiposae ; c, coil-gland suspended in the columnse adiposae ; h, sebaceous gland ; 
j>, horizontal prolongations of the column ; f, fibrous bundles of the corium ; g, pannicu- 
lus adiposus ; k, band of fibrous tissue extending into the panniculus adiposus. (After 
Warren. ) 

appearance, on longitudinal section, they admit of stretching of the 
skin. The individual fibres do not branch, but such an appearance 
is simulated by the joining of parts of different bundles. The elastic 
fibres (elastin) occupy the entire corium and extend throughout the 
subcutaneous tissue. These fibres by anastomotic branches form a 
network which surrounds the collagenous bundles and all the other 
elements of this region acting as a supporting framework. These 
fibres vary in thickness from imperceptible fineness up to 11/* in 
breadth (Stohr) and have little elasticity. They are the first to rup- 
ture when the skin is stretched, as is demonstrated in the " Linese 
albicantes," and their chief function appears to be that of support. 

The cellular elements of the corium consist of connective tissue 

corpuscles, vacuolated cells (Schafer), mast-cells, and migratory 

blood cells. (Description of these cells pp. 78-79.) The fibres and 

bundles of connective tissue are coarsest toward the subcutaneous 

1 Quoted from MacLeod. 



THE TRUE SKIN. 23 

tissue, and finest in the outermost portion which comes in contact 
with the epidermis above. They form the mesoblastic portion of the 
hair-follicle, the capsules around the coil-glands, and the layers which 
surround their ducts. 

Corresponding with their anatomical structure the upper and 
lower portions of the derma are called respectively the " papillary 
layer " and the " reticular layer." There is no sharp dividing-line 
between these layers, the pars reticularis passing gradually into the 
pars papillaris above and into the subcutaneous tissue below. 

Pars Reticularis. — The reticular layer of the corium is made up, 
as has been seen, of interlacing connective-tissue bundles, with inter- 
spaces increasingly larger from within outward. The fineness of the 
bundles decreases, in the same way, from without inward, being finest 
where the minute papillae of the corium project into the rete, and 
coarsest near the subcutaneous tissue. 

Pars Papillaris. — The papillary layer of the corium lies in con- 
tact with the rete above, and is connected below with the deeper retic- 
ular portion of the true skin. Between the rete and the papillae of 
the derma a hyaline substance is interposed, which is supposed to be 
identical with the cement-substance surrounding and separating the 
fibrillar of the corium. The basal membrane once thought to be 
stretched between the rete mucosum of the epidermis and the papil- 
lary layer of the corium cannot be demonstrated to exist. 

Viewed obliquely with an amplification of about three hundred 
diameters, it will be seen that long and slender filaments from the 
prickle-cells of the mucous layer of the epidermis encircle in a spiral 

Fig. 4. 







Vertical section of skin after injection (from beneath) of areolar tissue with 
Berlin blue : a, epidermis ; f, corium ; g, panniculus adiposus ; h, sebaceous gland. 
(After Waeeen.) 

direction both nervous and vascular papillae. At the apices of the 
latter these threads completely surround the connective-tissue fibres. 



24 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



The name of this portion of the derma is intended to describe its 
chief characteristics, the existence of numerous digital prolongations 
or nipple-like prominences of the corium, made up of delicate connec- 
tive-tissue fibres which do not interlace and which are abundantly 
provided with nuclei. The papillae spring each from a single, or 
several from a common, ovoid base; their bulbous, conical, or blunt 
apices reach into the rete, which also dips down between them in pro- 
longations termed " rete-pegs." The papillae vary in size in different 
parts of the body, and also in their disposition and shape, being in 
places arranged in linear series, and in others in concentric whorls, 
with definite centres, thus producing crossing-furrows, visible to the 
naked eye as markings upon the outer surface of the epidermis. The 
largest are found on the palms and soles and over the inner faces of 
the digits. It has been estimated that one hundred are developed 
within each square millimetre of the body-surface. 

In horizontal sections of the skin the papillae, being transversely 
divided, appear as circular or ovoid areas, in which can be recognized 
centrally a transversely or obliquely divided capillary loop. Between 
these areas is seen the interpapillary reticulum of the mucous layer. 

The growth of the rete downward and of the corium upward re- 
sults in mutual effects of pressure and counter-pressure, the equilib- 
rium of which is constantly adjusted by the mechanical and vital 
necessities of such union. 

When the papillae are completely exposed, after removal of the 
overlying cement-substance and of the epidermis above, their exterior 







d c 

Vascular and nervous papillse : a. vessel ; 6, nervous papilla ; c, vessel ; d, nerve- 
; e, corpusculum tactus ; f, transversely divided nervous filaments ; g, epithelia of 
(After Biesiadecki.) 



librC , Oj LUlJ.M.I.K.Uli.tlll l.ULU 

rete. (After Biesiadecki.) 



TEE EP1DESM1S. 25 

surface is seen to be uniformly marked with series after series of 
alternating furrows and ridges of exceeding delicacy and more or less 
concentrically disposed. Into the grooves are admitted corresponding 
dentations that can be recognized on the under surface of the layer of 
epithelial cells next the corium. They may, however, be the furrows 
left after separation of the long prickles wrapped about the papillae 
and traceable to the mucous layer. 

Two varieties of papillae are distinguished — the vascular and the 
nervous ; the former contain the terminal loops of a minute artery and 
vein, and the latter the terminations of medullated nerve-fibres. 

The greater number of the papillae are of the vascular variety, 
being traversed by a vertically disposed loop of vessels, consisting of 
an arterial and a venous capillary. The office of the vascular loop is 
evidently not merely to supply nutriment for the epidermis above, but 
also to provide for the cooling of the blood when brought in large 
quantities to the surface of the body. Occasionally, two or more of 
such loops can be recognized in a single papilla. 

The nervous papillae contain the tactile corpuscles, which subserve 
an important purpose in providing for the sensibility of the integu- 
ment. The tactile corpuscles are described in connection with the 
nerves of the skin. Ultimate terminations of nerves can be recognized 
in the vascular papillae, and at times minute vascular loops can be 
seen in the papillae largely occupied with the corpuscles of touch. 

Lines of Cleavage. — Puncture of the skin with a rounded instru- 
ment leaves an irregularly longitudinal slit. This phenomenon oc- 
curs as a result of the arrangement of the connective-tissue bundles and 
fibres of the corium. Dupuytren 1 studied this in the skin of the palm 
and Langer and Heitzmann 2 later mapped out the special directions 
over the entire body in which these lines occurred. 



THE EPIDERMIS, SCARF-SKIN, OR CUTICLE. 

The epidermis is the most external of the several membranes of 
the body, being in close contact on one side with the corium, or true 
skin, and exposed on the other to the atmosphere by which it is sur- 
rounded. The latter surface is therefore relatively drier, while the 
former is constantly moistened by fluids from the vessels which 
ramify beneath it. It is of epiblastic origin and is made up of super- 
imposed strata of epithelial cells, and varies in aspect and thickness 
according to its anatomical situation and the age of the subject. 

~No genetic relation exists between the epidermis and the corium, 
notwithstanding their intimate union and mutual relationship. The 
epidermis is developed from the ectoderm, the corium from a super- 
ficial layer of the mesoblast. Their behavior both in health and in 
disease is marked by the widest difference. 

The epidermis varies greatly in thickness in different portions of 

1 Uber die Verletzungen durch Kriegswaffen aus der Franz., 1836, p. 27. 

2 Archiv f. Derm. u. Syph., 1890, xxii., p. 3. (Quoted from MacLeod.) 



26 



ANATOMY AND PHYSIOLOGY OF TEE SKIN. 



the body ; for example, the epidermis of the palms and soles exceeds 
in vertical section that which covers the dorsum of the hands and feet, 
and that which protects such sensitive parts as the eyelids, lips, 
temples, and prepuce. The epidermis is composed of the following 
principal layers, named in order from within outward: the stratum 

Fig. 6. 




Scalp of a negro — horizontal section : R, rete mucosum : Pi, row of columnar 
epithelia (cut obliquely) supplied with dark-brown pigment-granules ; Pa, papilla (cut 
transversely) ; D, derma. Magnified 500 diameters. (After Heitzmann.) 

mucosum, the stratum granulosum, the stratum lucidum, and the 
stratum corneum. All of the cells composing these various layers 
are derived from the basal layer of the rete. Beside these, Ranvier 
and others recognize a stratum germinativum, a stratum filamen- 
tosum, a stratum intermedium, and a stratum disjunctum. 

Rete Mucosum (Mucous Layer, Prickle-Layer, Stratum Mucos- 
um, Rete Malpighii or Malpighianum) .- — This is the deepest of the 
epidermal layers, and rests upon the corium below. It is generally 
designated as " the rete." The corium is intimately united with it 
by a series of interdigitations, which are commonly described as 
prolongations of the derma into the substance of the rete, but it is 
equally true that the rete sends down prolongations (the " rete-pegs ") 
into the derma. The two, in the need of an intimate union to resist 
friction and to insure vascular supply, are thus closely locked 
together. 

The stratum mucosun is built up of nucleated epithelial cells, 
which are polyhedral in outline. These cells are masses of granular 
protoplasm, living matter, which by their relation to one another 
form a protoplasmic network enveloping the entire surface of the 
body and lining all channels and cavities in direct or indirect con- 
nection with the surface. These elements are flattened by reason of 
their apposition, and are separated from one another by an intercellu- 
lar cement-substance. There is a system of channels between the epi- 
thelia by which the nutritive fluids are conveyed from cell to cell. 
All are, however, uninterruptedly united by delicate spokes, known as 



TBE EPIDE&M1S. 



27 



prickles, spines, or thorns. The epithelia are unprovided with either 
blood-vessels or lymph-vessels ; but are supplied with a large number 
of nerves, which, in the shape of very minute beaded fibres, traverse 
the intercellular substance, and which are in direct communication 
with the reticulum of living matter within the protoplasmic bodies 
themselves. 

The masses of protoplasm just described play the most important 
part in all the pathological and physiological processes observed in 

Fig. 7. 




Prickle-cells from a condyloma (magnified about 625 diameters) : a, cavity of cell- 
nucleus ; b, nucleus ; c, nucleolus ; d, prickles — these are greatly developed on the proto- 
plasm of the cells. The dots on the surface of the protoplasmic mass represent the 
appearance of the prickles when directed toward the eye of the observer. Some of the 
protoplasmic threads are seen passing from one cell to another. 



the skin. It is probable that in the embryo all the appendages of 
the skin are formed directly by their assimilative and reproductive 
processes ; and it is certain that in health and in disease they are the 
ultimate source of all secretions. 

Next the corium is a layer (basal layer, stratum germinativum) of 
cells, columnar in form, often largely provided with pigment, and ar- 
ranged with their long axes nearly at right angles to the plane of 
that portion of the corium upon which they are superimposed. The 
cells of this layer are dividing constantly by mitosis, the daughter- 
cells pushing outward to form the succeeding layers. The entire epi- 
dermis thus is derived from this single (occasionally double) row 
of columnar cells. More externally the cells are rounded or cuboidal 
in shape, with large, distinct nuclei. They are not arranged in 
definite strata except in the outermost layers, where the cells are some- 
what flattened and elongated (stratum filamentosum) . Between the 
cells in the deeper layers outwandered leucocytes may at times be 
recognized. 

Langerhans' Cells,— These are elongated, irregularly stellate, non- 
nucleated bodies found chiefly in the deeper parts of the rete. They 



28 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

have been looked upon as pigment-cells devoid of pigment, as wander- 
ing cells, lymphoid cells, and as colorless tissue-corpuscles. 

Stratum Granulosum (Granular Layer). — The stratum granu- 
losum of the epidermis, lying immediately above the stratum filamen- 
tosum, is built up of three or four rows of horizontally disposed 
granular bodies, united to one another by short, broad threads. Be- 
tween these bodies the intercellular spaces are so contracted that 
nutritive fluids cannot easily filter outward; and the nuclei of the 
cells are usually shrunken. These have been studied carefully by 
Eanvier, Kolliker, Waldeyer, and others. According to these observ- 
ers, the roundish granules which give this layer of epithelium its 
name and peculiar appearance consist of keratohyalin, 1 a substance 
that plays a part in the process of cornification. These granules 
first appear in the neighborhood of the nuclei of some of the large 
prickle-cells in the rete, but they are best studied in the granular layer 
the cells of which are often completely filled with them. According 
to Unna, the color of the skin in the white races depends upon this 
layer alone. 

Stratum Lucidum (Septum Lucidum) of Oehl lies immediately 
above the stratum intermedium, and appears under the microscope 
as a delicate, brightly colored line consisting of two or three rows 
of transversely disposed glistening epithelia, differing in translucency 
from those situated on either side. The stratum lucidum thus marks 
with tolerable distinctness the boundary -lines of the rows of cells 
above and below it. Its epithelial bodies seem to have lost suddenly 
the refractive, shining granules of keratohyalin conspicuous in the 
stratum granulosum below, and to have acquired the oily looking sub- 
stance termed elei'din. 

Stratum Intermedium (Ranvier). — This is practically a subdivision 
of the stratum lucidum, from which it is distinguished chiefly by 
the fact that it takes a reddish stain after treatment with picrocar- 
mine. It is here that the process of keratinization of the epidermis is 
first to be detected. 

Stratum Corneum (Homy Layer) of the epidermis is its outer- 
most and widest layer, extending from the stratum lucidum below 
to the external environments of the body. In its lower portion the 
polygonal plates of which it is composed indicate very clearly their 
relationship to the cells in the prickle-layer. The nuclei appear in 
places only as shrivelled and inconspicuous relics of the protoplasmic 
threads ; or there may be merely vacant nuclear spaces marking their 
original site. Occasionally, on the edges, rudiments of the prickle- 
threads may still be recognized. More externally the dried, lifeless, 

1 Keratohyalin is a solid or semisolid substance which is situated in the stratum 
granulosum, and is differentiated well by a hematoxylin stain. It is insoluble in 
ether, alcohol, and chloroform, but is "destroyed by strong acids and alkalies. 
Chemically it is of the nature of hyalin. 

Ele'idin is an oily-looking, though not a fatty, substance, situated in the stratum 
lucidum. It differs from keratohyalin physically and chemically, but MacLeod sug- 
gests that it may be a derivative of keratohyalin. Its differentiation requires 
special staining methods. Cf. MacLeod's Pathology, p. 61. 



TEE EPIDERMIS. 29 

horn-like plates of which this layer is composed become mere corni- 
fied shells, generally lying in horizontal strata, and becoming more 
curled and wrinkled as the surface of the skin is reached, often being 
imbricated, but preserving the polygonal outlines of epithelia re- 
lieved of the forces of pressure and counter-pressure exerted in the 
deeper parts of the epidermis. These elements are rarely pigmented, 
save in the case of the negro, in whom the intense staining of the 
deepest parts of the mucous layer extends measurably to the external 
strata. This staining in the colored races is produced by granules of 
pigment arranged about an unpigmented nucleus in the prickle-cells. 
The cells of the horny layer contain fatty material in very consider- 
able proportion, a provision by which the suppleness of the skin is 
maintained and undue evaporation prevented. Neither keratohyalin 
nor elei'din is found in this layer, but there appears in their place a 
resistant substance termed keratin, to which the hard, dry character 
of the cells is due. Keratin is insoluble in 50 per cent, dilution of 
mineral acids, and resists digestion in a solution of pepsin con- 
taining weak hydrochloric acid, but is soluble in weak alkaline 
solutions. 

After digestion with pepsin and trypsin the horny cells may be 
seen to be connected by more or less persistent threads, visible after 
prolonged digestion as a large-meshed reticulum, with strands formed 
from a double row of cornified filaments united by short horny 
bridges. 

Stratum Disjunction (Ranvier). — This is the most superficial of 
the layers of the stratum corneum, differing chiefly from the latter in 
that it is indifferently colored by osmic acid. 

Spiral Fibers. — Herxheimer's 1 spiral fibers are found chiefly be- 
tween the cells of the rete and basal layer of the epidermis. They 
are most abundant normally in the lower part of the rete and become 
increased in number in inflammatory conditions. They lie for the most 
part parallel with the long axes of the rete-cells. They sometimes 
are found between the cells of the inner root-sheath of the hair folli- 
cle. Opinion differs as to their nature. Jadassohn, Ehrman, 2 Mac- 
Leod, 3 and others believe them to be spirals of fibrin. This seems 
probable since they are increased in number when an inflammatory 
reaction is present and since they occupy the lymph-spaces between 
the cells and in size correspond to these spaces. They have in the 
past been regarded as elastic fibres protruding from the corium be- 
low; as parts of a canal system for conveyance of nutriment to the 
cells of the epidermis, etc. 

Cornification. — The process by which the epithelial cell from the 
basal layer of the rete becomes transformed into the hard resistant cell 
of the stratum corneum has been studied at length, and the part 
played by the keratohyalin of the granular layer, and elei'din of the 

1 ArcMv f . Derm. u. Syph., 1889, p. 645. 

2 Arehiv f. Derm. u. Syph., 1892, Erganzungsheft, i., p. 307; and Monats. f. 
prakt. Derm., 1897, xxiv, p. 549. 

8 MacLeod, Histopathology of the Skin, 1903, p. 59. 



30 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

stratum lucidum in the formation of keratin has caused much contro- 
versy. While as a rule when cornification is perfect both kerato- 
hyaline and elei'din are present normally, and when these two are 
absent or imperfectly formed cornification is incomplete, yet cornifi- 
cation may occur without the intercurrence of these substances. Mac- 
Leod considers " keratohyalin as a separation product of the proto- 
plasm of the cell which appears as the vitality of the cell is dimin- 
ishing; ele'idin, a further product of the same substance; and the 
ultimate product of both is probably the fatty or waxy substance 
which is present in the horn cells." The same author states further: 
"The intercellular bridges or prickles would, according to this hy- 
pothesis, become hardened into keratin by an inherent power of their 
own in much the same way as the fibro-vascular system of a leaf at the 
fall of the year becomes hardened into a brittle leaf skeleton." 

BLOODVESSELS. 

The arteries and veins supply the skin from subcutaneous branches 
which penetrate the underlying fascise, and proceed by subdivision to 
be distributed to all portions of the integument below the epidermis, 
the distribution being especially abundant aboul the glands and fol- 
licles of the skin and the inferior and superior parts of the corium. 
They arc always more abundant upon the flexor than upon the exten- 
sor faro- of the extremities. Just beneath the papillary layer of the 
corium there is a minutely ramifying plexus of fine capillaries, the 
[oops of which extend into the papilla above. This and the coarser 
plexus in the deeper portion of the donna are w< 11 defined, and have 
been designated as superior and inferior partes vasculares of the 
corium: also, as the upper and Lower vascular net. Th< 
nected by more or Less regularly placed and nearly vertical communi- 
cating branches. A fourth division of the vascular system of the -kin 
is found in the subcutaneous connective tissue, in which the vessels 
are numerous; a fifth is represented by th< 1 to the 

papilla?; and lastly, a Bixth includes the vascular channel- supplying 
the accessories of the integument. 

The arterioles which supply the Bweat-glands surround the coils 
of the latter in a delicate basket-like plexus, and terminate in two or 
three veinlets. one of which always accompanies the duet of the gland 
upward as far as the papillary layer, where it anastomoses with the 
vessels of that part of the skin. The ascending arterioles supply the 
sebaceous gland- and hair-follicles, and, breaking up into smaller and 
yet smaller branches, finally furnish a simile or a double capillary 
loop to each papilla. These capillaries of the papillary layer anasto- 
mose freely with those transversely arranged in the upper portion of 
the hair-follicles, from which loops i the sebaceous elands. 

The hair-papilla has a vascular supply similar to that of each of the 
other papilla of the corium. 

Unna divides the vessels distributed to the skin into the papillary 



LYMPHATIC VESSELS. 31 

system and the system of the coil-glands and fat-tissue. The first 
system includes the ascending loops which traverse the vascular pa- 
pillae, and the branches supplying lower portions of the corium. The 
second system embraces the vessels running upward to the coil-glands 
and downward to the fat-tissue. In the papillary vascular system the 
arteries are narrow and the veins wide. Each of the vessels consists 
merely of an endothelial tube augmented, as the subcutaneous tissue is 
reached, by both media and adventitia. According to Hover, a sin- 
gular duplex arrangement of vessels in the distal phalanges of both 
fingers and toes results in a distinct communication between the arte- 
ries and veins. Other observers deny the existence of such anas- 
tomosis. 

Vasomotor nerves are twined around these vessels in all their 
ramifications. The whole vascular system, as thus arranged, plays a 
most important part in all the healthy and morbid processes which 
occur in the skin, as well as in the physiological changes distinguish- 
able to the eye in the phenomena of blanching and blushing. 

LYMPHATIC VESSELS. 

The skin in all its parts is provided with a closed system of lym- 
phatic channels, designed to subserve the necessities of the important 
processes of absorption, and is traversed by lymph the currents of 
which are continuously directed to the large vessels of the structures 
beneath the skin. These channels include: first, juice-spaces, pro- 
vided or not with independent walls, usually without, and not freely 
communicating with the endothelium-lined vessels ; second, lymphatic 
vessels proper. These conduits do not connect with blood-vessels. 

The juice-spaces, or lymph-spaces, separate the epithelial bodies 
which make up the stratum mucosum of the epidermis, and they also 
extend between the protoplasmic threads, or prickles, that unite them. 
Such conduits may be regarded either as delicate excavations in the 
cement-substance between the epithelia, or as irregular channels in a 
soft, viscid, albuminoid, and readily coagulable substance between the 
protoplasmic threads. At times this intercellular substance seems 
capable of obstructing the conduits by which it is tunnelled. These 
juice-spaces exist in the papillae of the corium, and encircle the 
several glands, hair-follicles, and nail-beds of the skin. They also 
sheathe the connective-tissue fibrillar of the corium and surround the 
fat-cells. According to Darier, the derma is a " true lymphatic 
sponge." 

The lymphatic vessels are relatively few, but they form a continu- 
ous meshwork with transversely and vertically disposed branches 
supplying all parts of the skin below the epidermis. The juice-spaces 
communicate with these vessels in the papillary portion of the corium 
through minute orifices in the vascular walls, the vessels themselves 
being here represented by blind terminal loops. As these vessels pass 
to the deeper portions of the corium and below it they increase in size. 



3 9 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

mmmmm 

tion of fat by filtration is facilitated. 
NERVES. 
Thr B Mn in view of the number and mode of distribution of its 

liiilli! 

""■ » '''"T SmJA; Plicate 6bres, penetrate 
mate bulboTK town* id ,l ' 1 ".^ !,.,.,, is su| ! ) ,i i ,. ( l with a 

StaMMWS plion^tionintheshini. 

-lS£f3L— . are also diatriW to A. , *-U- . d the U£ 
ve«els (vasomotor nerves), in ^^^J^dtJtaS 

upward into tbe papilla, ana men w revercion? aga in ascend to 

Kaee^maT^r^pS^ ^aeX and tactile 

C ° rP paclnian Corpuscles (named from the anatomist Pacini), al* 
cJZ^puscHof Vafer, exist suhcntaneously only npon nerve 



NERVES. 



33 



intended for cutaneous supply; they are ovoid bodies, two or more 
millimetres in diameter. Each corpuscle consists of a series of con- 
centric, nucleated, vascular capsules, arranged after the manner of the 
capsules of the onion, more closely united at the periphery than at the 
centre, and surrounding a protoplasmic core. The medullated nerve 
to which the body is attached gradually loses its myeline envelope; 
and terminates in the centre of this core, after traversing the greater 




Pacinian body, after silver stain- 
ing, showing superimposed endothe- 
lial layers. (After Renault.) 




Section of Pacinian body from a duck's 
bill : g.L, lamellar envelope ; g.h, hyaline zone 
of the lamellar envelope ; b.t, terminal bulb of 
the nerve ; g.p, n.g.p, layer investing the cavity 
of the body. (After Renault.) 



part of its axis, in one or several minutely club-shaped filaments. The 
myeline sheath is lost in the tissue of the concentric capsules. The 
nerve may, after supplying one capsule, penetrate a second or even a 
third. In such cases the nerve regains its sheath as it issues from the 
corpuscle at its opposite pole. Robinson believes that the nerve forms 
a plexus or loop within the corpuscle, and escapes from it at one of 
its poles. 

The precise function of the Pacinian corpuscle is unknown. Its 
connection with the tactile sense is suggested by its location, since 
these bodies are most numerous in the subcutaneous tissue of the 
nipple, the penis, the digits, and in parts similarly sensitive. These 
corpuscles bear an analogy to the organ of vision; each body having 
a capsular character; each being provided with a special nerve- 
filament, which enters the corpuscle at one pole; each also receiving 
its impressions at the extremity of the capsule opposite that at which 
it receives its nervous supply. 

:, According to Krause, the Pacinian corpuscles aid in the appreci- 
ation of impressions produced by pressure and traction. Whether 



34 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 



specially concerned in distinguishing Bensations of heat, cold, mois- 
ture, pressure, traction, or weight, il is evident that they contribute 
but little, if at all, to the perception of ordinary impressions upon the 
skin, and they are not known 1<> play any pail in cutaneous diseases. 



Fig. 9. 




Section of :i papilla siiii covered by a portion ->f the Btratnm mucosum and contain- 
ing a tactile bodj (from the skin of a Anger). Th< rpuscle ol Melssner Is 

consist "i' minute lobules, made up of a homog plasm, with numei 

nuclei and nervous fibrilla? wound in a spiral direction about the mass of the corpuscle 
The extensh r the fibrllle to tin- mucous layer is shown. The courses of the nerve- 
filaments are demonstrated t" be: >li the axis-cylinders •>( one or two double-contoured 
nerve-fibres, splitting Into their original fibrills on arriving at the corpuscle, winding 
about tin- latter in characteristic spirals, ami passing to tin- pallsade-layei 
prickle-cells of the rete, between which, on accounl of tin- long prickles of tin- latter and 
tin' general resemblance of the two in thickness and contour, it is difficult to trace them 
further; r2\ filaments from another double-contoured nerve-fibre (h) pass directly bo 
the inferior layer of cells in the rete without establishing relations with th< 
body: i •". i fibrillar derived from the network of nervous fibrilla? In the pars papillaris of 
the corium iA>. also passing more or less directly to the stratum mucosum. a 
the rete; b, prickles of the latter: c, body of papilla: <i . nuclei of connect) 
forming papilla; e, protoplasmic part of the tactile body with its nuclei: f, fibrilla; of 
the corpuscle; '/. double-contoured nerve-fibres directly supplying the rete; If, nervojis 
fibrilla: derived from the network in the pars papillaris: I. nervous fibrillie entering the 
epidermis between the rete-cells, leaving the corpusculum tactUS at in. 



Tactile Corpuscles (Corpuscles of Meissner, or of Wagner) are 
ovoid bodies found in about one in four of the papillae in the pars 
papillaris of the corium. Each corpuscle is composed of from one to 
three capsules. Minute lobules of a homogeneous protoplasm with 
oval nuclei are found in each. These corpuscles receive medullated 
nerve-fibres, and are made up of closely compressed, flat connective- 



NEEVES. 



35 



tissue fibres with minute nuclei, which are so packed together as to 
form a spindle-shaped mass occupying the greater part of the papilla 
in which each corpuscle is found and surrounded by a somewhat 
denser connective-tissue capsule. The myeline sheath of the nerve- 
fibres is lost in the fibrous tissue of the corpuscle. Externally viewed 
they seem to be transversely striated. 

The axis-cylinder of the nerve-filament distributed to each cor- 
puscle divides into numerous delicate nerve-threads which in part 

Fig. 10. 




Transverse section of nervous papilla surrounded by cells of the stratum mucosum : 
a, protoplasmic lobules of the corpusculum tactus ; b, nervous fibrillse spirally wound 
about the latter ; c, transverse section of double-contoured nerve-fibres ; d, cavity of 
nucleus (out of focus). 



encircle the corpuscles and also penetrate within. Each corpuscle is 
provided with an afferent and an efferent nerve, the former approach- 
ing the corpuscle from the subpapillary region and entering at or near 
its base. Occasionally the afferent fibre is furnished by an adjacent 
papilla. As the filament that enters the corpuscle frequently divides, 
two or more efferent fibres may then escape from it. Afferent fibres 
reach the rete above after encircling the tactile corpuscles ; others, side 
by side, arrive at the rete without coming into contact with the former. 

The discovery of nerve-filaments in and among the epithelia of the 
epidermis in such abundance as to provide fully for tactile sensation 
in the skin leaves the exact function of these corpuscles in partial ob- 
scurity. There can be little doubt, however, as to their association 
with the perception of certain qualities of foreign bodies with which 
the skin may be brought into contact. 

Touch-cells.- — Merkel's Touch-cells are oval, nucleated bodies 
found in the lower animals, but also in man. They are supposed to 
be connected with the ultimate nerve-fibres. They resemble cells in % 



36 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

mitotic state, and are found in the upper parts of the corium as well 
as the epidermis, and in regions in which the tactile corpuscles are 
few, as over the abdominal surface. 

Corpuscles of Krause (Bulb-corpuscles: Kolbenkorperchen ) are 
rounded or oval-shaped bodies formed of a connective-tissue envelope 
and a non-nucleated bulb to which some delicate nerve-fibres pene- 
trate. These bodies are found chiefly along the borders of the lips. 
over ihe glans penis, the clitoris, and the tongue. 

PIGMENT. 

The hue of the living integumenl is due in part to the degree of 
vascularity and distention of the vessels in the corium, and in part 
also to pigmentation of the epidermis. The coloring-matter of the 
skin in health La deposited chiefly in from one to four rows of cell- in 
tlic Lower stratum of the rete, the fine granules of pigment staining 
belli the cell-body and the nucleus, the latter more vividly. The pig- 
menl of the "-kin depends for it- hue upon a substance called melanin, 
which occur- in amorphous granules of an albuminous material con- 
taining sulphur, lis office is obvious. It is designed to abort i 
light and thus to aid in the protection of the body from undue 

Llisolat [on. 

The degree of vascularity of the -kin i- responsible for mosl of 
the flesh-tints, but the colors Been in ihe various races "t* men are 
wholly related i" the character and quantity "f pigmenl found in the 
rete. Rarely, pigment-cells are found in the corium in a state of 
health. This pigmentation depends upon a distinct and uniform 
coloration of the epithelia, and also upon minute granules of melanin 
entangled in ihe reticulum of living matter in the Bame part. K\ 
treme variation in ihe distribution of pigment i- noticeable l'"th in 
healtb and in disease, and in individuals and races, being at limes 
related t<» climatic and similar influence -. 1 hi- fad i- well illus- 
trated by ihe vide range between ihe flaxen-haired, pink-eyed albino 
and the blackest specimens of the negro, each, with -mall exception, 
being of African descent. 

It has already been n<>ie<l that in the colored races ihe pigment 
may -tain the epithelial cells and their nuclei a- high a- the granular 
layer; and that to this layer only i- due the characteristic color of the 
skin of the white races. Pigment i- not normally found either in the 
horny layer of the skin or in the subepithelial li-- i< -. Waldeyer 
claims to have recognized it in normal connective tissue. 

The source of the pisrment in the skin ha- not been positively de- 
termined. Tt is believed by Borne to be carried by leukocytes from the 
corium beneath to the rete above: others have thought that the pig- 
mented cells themselves were capable of migration. Yet others 
that the pigment is produced de novo within the rete-cells. Tt i- rno-t 
probable that the pigment i- derived from the subepidermal struc^ 
tures, and is originally obtained from the blood itself. 



MUSCLES. 37 

The relation existing between the two sources of skin-coloration, 
viz., the blood and pigment, is interesting and suggestive. The un- 
aided eye, looking at the outer surface of the body, makes little dis- 
tinction between these two color-sources. It is certain that solar heat 
exerts a manifests influence upon both, and that in extravasations of 
blood into the substance of the skin every shade of color visible in 
the spectrum may at times be distinguished. 

MUSCLES. 

Striated Muscular Fibres extend from the subcutaneous tissue 
into the derma; in the case of man they are found chiefly upon the 
face and neck, where they are the analogues of more powerful skin- 
moving muscles possessed by several of the lower animals. Some, as 
those in the region of the face, serve to give expression to mental 
emotion by the production of facial movements. 

Non-striated Muscular Fibres exist either as minute oblique fas- 
ciculi in connection with the glands and follicles of the skin; or as 
annular bands, such as those which surround the nipple; or as radi- 
ating and more or less parallel rods, such as antagonize the orbicularis 
in the eyelids. 

Arrectores (Erectores) Pilorum.— These muscles are found usu- 
ally in connection with the hair-follicles. They originate by minute 
multiple fasciculi from the papillary portion of the corium, and are 
inserted at several points into the outer layer of several adjacent 
hair-follicles, just above the plane of the apex of the hair-papilla. 
Their general direction is oblique, and their muscle-bundles are em- 
braced and traversed by elastic fibres which form a dense network 
about them. Elastic threads also connect them intimately with the 
connective-tissue bundles of the corium, and serve as tendons at 
either extremity of each muscular fasciculus. 

The muscles, by virtue of their oblique direction and mode of at- 
tachment, include in the angle subtended by their muscular fibres the 
sebaceous glands connected with the hair-follicles. It follows, there- 
fore, that by their contraction they aid in the expulsion of the seba- 
ceous secretion formed in the gland; but their intimate union with 
the elastic tissue, which is evenly and generally distributed through- 
out the framework of the corium, results in their discharge of a still 
more important function in connection with the regulation of the 
body-temperature, since by virtue of direct compression exerted upon 
the skin the blood may be driven from the surface in a centripetal 
direction and its cooling in a great degree prevented, as in the well- 
known phenomena resulting in the production of the cutis anserina, 
or "goose-flesh." The reverse of this naturally follows when the 
muscles expand under the influence of external heat. The anatomical 
connections of the arrectores pilorum are such that their contraction 
serves to approximate several of the papillae of the corium, including 
the hair-papilla. Thus, by their contraction the sebaceous secretion 



38 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

may be extruded, or, as is more particularly exhibited in the lower 
animals, such hairs as the bristles of the boar may be erected. 

Muscular Membranes exist in the skin of the scrotum, over the 
penis, about the nipple, and elsewhere. They are simply layers of 
smooth muscular fibres, which suffice when contracting to move the 
portions of skin to which they are distributed. 

HAIRS. 

Hairs arc cylindrical, elongated, and pointed epithelial filaments, 
derived from the epidermis, and obliquely implanted in depressions in 
the rete and corium, known as " hair-sacs," or " hair-follicles." They 
are found on all the superficies of the body excepl the palms and soke, 
the dorsum of the distal phalanges of the hands and feet, and the skin 
of the penis. Eairs occur in three tolerably distincl classes. These 
are: the fine, downy hairs, or lanugo, covering the face, the trunk, and 
tl, ( . limbs; the Long, wfl hairs, Bucb as those implanted upon the scalp, 
the pubes, and the axillae; and the Bhorl hairs, including the Bofl va- 
rieties seen upon the brow and the stiff hairs of the eyelids. 

The hairs are firal developed in the third month of foetal life, 
when a Bhorl epithelial cone is formed, the base of which is gradually 
surrounded by connective-tissue cells, and finally indented from be- 
low by a rudimentary hair papilla. Gradually the tip of the rudi- 
mentary hair perforates the primitive hair-cone and becomes a mature 

filament. At ahoul the period of birth, sometimes earlier, aaion- 

ally later, the " l.< d-hairs," aa thej are called by CTnna, are replaced 
by papillary hairs. The term bed-hair is applied to primary haira 
unprovided with papillae, and implanted in Bhallow follicles, from the 
sides of which productive epithelial offshoots have been Benl out 
Usually ai the end of foetal life these bed-hairs have been for two 
months growing out of the hair-bed, or thai pari of the epithelium 
found in the central pari of the hair-sac. 

Hair- thus differ from naila nol only in their anatomical feal 
bui particularly aa to their physiological reproduction. Hair- are 
periodically casl off and replaced by new filaments. The nails are 
Bhed and reformed only in disease; in health they enjoy a continuous 
growth during the life of the body. When a hair i- about to be shea) 
ii separates from its papilla in the hair-follicle and rises in the latter 
till it reaches above the level of the papillary apex. It is for a time 
held in place with sufficient firmness by the prickle-layer only, thus 
forming the bed-hair already described. Later an epithelial bud La 
projected either into the vacant follicle below or into the corium on 
either side, from which a new hair is formed, somewhat as the hair is 
formed in the primitive con.- of fetal life. The subsequent irrowth 
outward of the new papillary hair separates the bed-hair from its 
connection with the prickle-layer, and this filament is shi d. 1 

x Cf. Veneziam. Giorn. ital.. 1901, xxxvi.. 582 -tr. in Brit. Jour. Derm., 

1902, xiv.. p. 325). 



BAI&S. 



39 



In studying the mature hairs the parts to be considered are the 
hair-follicle, and the bulb, shaft, and point of the hair. 

Hair-follicle. — The hair-follicle is a sac-like pouch in the corium, 
in which depression the hair-filament is implanted by its bulb and 



Fig. 11. 





Section of a hair-follicle during the 
formation of a new hair : a, external and 
middle root-sheaths ; b, vitreous mem- 
brane ; c, papilla with vascular loop ; 
d, external root-sheath ; e, internal root- 
sheath ; f, cuticle of hair-follicle ; g, 
cuticle of hair ; h, I, young hair ; I, bulb 
of old hair ; k, debris of external root- 
sheath of hair recently expelled. (After 
Ebnee.) 



Hair-follicle in longitudinal section : 
a, mouth of follicle ; b, neck ; c, bulb ; 
d, e, dermic coat ; f, outer root-sheath ; 
g, inner root-sheath ; h, hair ; k, its 
medulla ; l, hair-knob ; m, adipose tissue ; 
n, hair-muscle ; o, papilla of skin ; p, 
papilla of hair ; s, rete mucosum, contin- 
uous with outer root-sheath ; ep, horny 
layer ; t, sebaceous gland. 



there firmly secured. The direction of this follicle is always at an 
oblique angle with the plane of the cutaneous surface upon which it 
opens, and thus is determined the set of the hairs, which is 



40 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

fixed and at a similar angle. Viewed as a whole, the integument of 
the body over its entire area exhibits determinate whorls of both 
short and long hairs with definite centres, such as those which may be 
recognized at the vertex of the scalp, the centres of the lips, the umbili- 
cus, etc. By this disposition the symmetrical appearance of the hairy 
parts is preserved, and, as a consequence of the same provision, physi- 
ological loss of the hair of the head is not productive of deformity, 
but rather adds dignity to the aspect of the elderly man. 

The hair-follicle embraces the lower two-thirds of that portion of 
the hair which is imbedded in the Bkin, together with the envelopes of 
the Latter, termed the hair-sheaths. Above the Bebaceous glands the 
sheaths of the hair-follicle are Lost in the papillary layer. The 
follicle is constituted of the connective tissue of the corium in three 
layers: an external longitudinal fibrous Layer; b middle transverse 
Layer; and an internal homogeneous or vitreous Layer. Ai the 1 >;< -<■ oi 
the sac a fibrous pedicle may often be traced as Low as the sub- 
cutaneous tissue. 

If the hair-pouch were made art ificially by thrusting into the skin 
from without inward ;i blunt pointed pin before which the tissue was 
gradually pushed, ii is evident that the external Layer, the Btratum 
corneum, of the epidermis would be the first depressed, and finally 
would form tin' Inner Burface of the pouch. This represents the inner 
root-sheath of the hair. Next i" this the pin would carry before it the 
mucous Layer of the epidermis, which then would form 1 1 * * - outer 
root-sheath of the hair, < hitside of both would Lie the connective tis- 
sue of the corium. 

Outer Root-sheath. The outer root sheath or the prickle-lay< r of 
the hair-follicle, accompanies the involutions of the Btratum corneum 
and the stratum granulosum from without into the funnel-ehaped 
neck of the hair-pouch as far as the openings of the ducts oi the se- 
baceous glands. There, abandoned by the two other layers of the 
epidermis, the root-sheath is thinned in proportion as the papilla, 
which rises from below and which ii closely surrounds, increases in 
size. It thus forms :i hollow cylinder traversed by the hair and its 
envelopes, with a relatively wide, external, funnel-shaped opening, 
only partially filled by the Bhafl of the hair, and a narrower opening 
within, which embraces the neck of the hair papilla. 

Inner Root-sheath.-- The inner root-sheath or "matrix" of the 
root-sheath, is externally in relation with the outer root-sheath, or 
prickle-layer, of the hair-follicle. The protoplasm of the cells of 
which it is constituted contains keratohyalin in varying quantities, 
the amount being naturally greater in the cells lying nearest the hair- 
filament. That part of the sheath formerly termed '•Hen].'- layer"' 
is the more externally situate.] cellular envelope of this internal root- 
sheath, and is most conspicuous in that part of the hair-sac above the 
level of the papilla. That part of the sheath formerly called "Hux- 
ley's layer" is the more internally situated part of the same sheath, 
somewhat higher in the follicle. These are not distinctly different 



EA1HS. 



41 



structures, but only a single structure in different situations. 
Whether termed the internal root-sheath or the matrix of the root- 
sheath, it springs from the neck of the papilla, and rises as high as 
the neck of the follicle. It contains keratohyalin, which is actively 
concerned in the cornification of the hair-tissue. 

Between this internal root-sheath and the cells constituting the 
cortex of the hair there is found, according to Unna, the common 
matrix of the cuticulse, forming respectively the cuticle of the root- 
sheath and the cuticle of the hair. The former is composed of cells 
with their long axes parallel with the circumference of the hair, while 

Fig. 13. 




Lower portion of hair-pouch from the lip of a kitten : F, follicle ; T, transverse 
section of connective-tissue bundles of derma ; M, arrector pili muscle ; 18, inner root- 
sheath ; 08, outer root-sheath ; P, papilla ; G, cuticle ; R, root of hair ; H, hyaline, or 
so-called "structureless," membrane. Magnified 500 diameters. (After Heitzmann.) 



those forming the cuticle of the hair are arranged perpendicularly to 
the surface. These cuticulse are locked securely together by projec- 
tion of their cell-edges, while united in the hair-follicle. 

Bulb. — The bulb or the root is that portion of the hair imbedded 



4'2 



ANATOMY AND PHYSIOLOGY OF THE SKIS. 



in the skin, toward which the shaft of the hair gradually increases in 
thickness as it descends. The bulb is embraced by the hair-follicle, 
though its root-sheaths are interposed and implanted below at the base 
of the sac upon a nipple-shaped prolongation of the corium thai may 
be regarded as analogous to the vascular papilla? of the papillary layer 
of the corium. 

The bulb of the hair embraces the papilla, and is constituted of 
pigmented cells externally, forming what is called the "cortex" or 
cortical portion. This is the larger of the two structures of which the 
hair is composed, and its cells become vertically elongated and narrow 
as they are push d outwards in the process of growth. 

Shaft. The shaft of the hair is thai portion which extends from 
the exit of the hair a1 the Burface of the skin to its extremity; the lat- 
ter, when uncut, always tapers to a perfectly acuminate point, as 
illustrated by the nncnt hairs of the eyelids and those of the lower 
animals. The hair-shafl is either straight, curled, wavy, or alter- 
nately varied in diameter. A transverse section presenting an ovoid 
or ellipsoidal outline suggests an irn gularly compressed circle. The 
degree of this flattening varies in different races, and is the cause of 
variability with respeel i<> Btraightness or curliness. As hair- are to 
a marked degree hygroscopic, and not only absorb bul can l>e deprived 
of a portion of their water, these states of waviness are subjeci to 
variation according to the aqueous condition of the media by which 
an individual is surrounded. 

The color of the hair is dependent 
upon the pigmenl it contains, the color of 
the hair cells, and the quantity of air 
contained in the medulla. Variation in 
three factors produces the wide 
range between a snowy whiteness and an 
ebony black. 

The coloring-matter of the hair i- thus 
stored in both it- horny and it- medullary 
portions, and i- distinct both within and 

between the epithelial elements of which 
the hair i- composed. This pigmentation 
corresponds in great pari with the amount 
of pigment distributed to other par 
the integument, and sustains a close rela- 
tion to the general nutrition of the body, 
[ts - ibjection to the influence of the tro- 
phic nerves is well demonstrated by the phenomena of rapid blanch- 
ing of the hairs. Ex< - eating, whether physiological or in- 
duced by the action of pilocarpine, has also a distinct influence 
upon the shade of color of hair. 

The cuticle is the membrane which invests the shaft of th^ hair, 
composed of numerous flattened plates, non-nucleated and non-pi^ 
mented, regularly overlaid so as to resemble closely adherent fish- 



Pio. i f. 




Transverse section of hair and 
follicle. 



GLANDS. 43 

scales when viewed under the microscope on the flat side, and the 
overlapping tiles of the roof of a house when seen on the edge. 

Cortex. — The cortex of the hair, constituting the greater part of 
its bulk, is composed of flat, nucleated, pigmented, fusiform epider- 
mal cells. The strength, elasticity, and extensibility of the hair are 
chiefly due to the cortical substance, and in particular to the firmness 
with which these epidermal cells are attached to one another. 

Medulla. — The medulla of the hair is found best developed in the 
short, strong hairs of the beard and eyelashes, being wanting in the 
lanugo-hairs. It consists of a loosely packed mass of cuboidal cells 
with interspersed air-spaces, differing in shape, developed in the 
centre of the axis of the shaft. This part of the hair contains also 
the pigment and fatty matters, which are here arranged as in the 
rete of the epidermis. Seen under the microscope, the medulla ap- 
pears as a continuous or interrupted longitudinal band extending 
from the bulb, or the part implanted in the follicle, to the extremity, 
or point, of the hair. The purpose of this difference in the constitu- 
tion of the cortex and medulla of the hair is doubtless to insure, on 
well-known mechanical principles, a maximum of strength, extensi- 
bility, and elasticity, with a minimum of volume. 1 



GLANDS. 

Sebaceous Glands, or sebiparous glands, are pyriform bodies, usu- 
ally racemose in development, situated in the corium, never in the 
subcutaneous tissue ; they furnish a more or less consistent and fatty 
secretion destined to anoint the skin and hairs. They can usually 
be distinguished as of three classes, though only two of these classes 
include glands which are associated with hairs in the embryo. 

The first class includes the sebaceous glands, which, strictly speak- 
ing, are appendages of the hairs and hair-follicles. They are de- 
veloped early in foetal life from minute, lateral, bud-like prolongations 
from the outer root-sheath of the hair. , From two to six of these pro- 
longations spring from the prickle-layer of the hair-follicle, and the 
prickle cells in the axis of each bud speedily undergo fatty metamor- 
phosis. In the mature gland each acinus is formed of a membrana 
propria supporting layers of nucleated cuboidal epithelia furnishing 
fat. Gradually the fatty cells are pushed outward toward the duct 
of the gland, where, sooner or later, their rupture releases numerous 

1 Pinkus (Zeitschrift, 1902, ix., p. 465; Ibid., 1903, x., p. 225) describes peculiar, 
glistening disks, from 0.25 to 0.5 mm. in diameter, situated adjacent to the lanugo- 
hairs, and lying in the acute angle formed by the hair with the skin. They are most 
easily seen, by the aid of strong reflected light, on the flexor surface of the forearm 
or upper arm, but occur on other parts of the body. They are most numerous in 
males from eighteen to thirty years of age. Microscopically the structure differs 
slightly from that of normal epithelium, and by special staining shows a rich 
supply of nerve-fibrils derived from the nerve of the hair-follicle. These disks have 
been found in the skin of man only, but resemble closely the touch-plates found in 
crocodiles and in a peculiar lizard found in Australia. Pinkus believes that these 
hair-disks play a part in the sensory functions of the skin. 



44 



ANATOMY AND MYS10L0GY OF THE SKIN. 



drops of fat (sebum) just where the hair emerges from the closely 
applied follicle below to the funnel-shaped mouth of the hair-pouch 
above. Externally each gland is provided with a layer of connective 
tissue provided with blood- and lymph-vessels and nerves. Seba- 
ceous follicles are found in connection with the long, soft hairs, as 
those of the scalp and the axilhr. several being grouped around a sin- 
gle hair-sac. 

The second class includes the Large and complex glandular struc- 
tures to which the Lanugo-, or rudimentary, hairs Beera accessory, the 
orifices of their respective ducts opening directly upon the cutaneous 
surface. These glands are chiefly found upon the glabrous portions 
of the skin, as upon the face in both sexes and upon portions of the 
trunk and extrem.i1 ies. 

The third class includes those sebaceous glands, much the smallest 
in number, opening directly upon the Burface and unconnected with 
hairs or hair-follicles. Such arc the glandulse odorifene of the male 




Sebaceous glands of 



the alae of the nose. (After Bappbt.) 



and female genitalia, and those existing about the lips and in the 
areola of the nipple. These glands might be designated as " glands 
of the mucous orihV 



GLANDS. 



45 



Meibomian and Tysonian Glands. — These are of the largest order of 
sebaceous glands. The former exist within the free border of the eye- 
lids ; the latter, upon the glans penis and the inner face of the prepuce. 
They are unconnected with hairs, and in this respect differ from other 
types of sebaceous glands. 

Glandulae Ceruminosae. — These are situated in the sebaceous tissue 
of the meatus of the ear, and contribute to the waxy secretions there 
furnished. The " glands of Moll " found in the eyelids are to be 
classed with the sweat-glands. 

Coil-Glands. — The coil-glands (Siveat or Sudoriparous Glands, 
Glandulce Glomiformes) , found within the skin of all regions of the 
body, are globular coils situated in the subcutaneous tissue and in 
the deeper portions of the corium. They appear first in the fifth 
month of foetal life as buds projected downward from the prickle-layer 
of the epidermis. These 
projections always form 
between the papillae of the 
corium, and spring from 
the rete-pegs between these 
papilla?. Long, thin cones 
of epithelium thus gradu- 
ally traverse the corium, 
and become slightly bul- 
bous at the lower extrem- 
ity to form later the coil. 
The lumen, when formed, 
extends rapidly to the epi- 
dermis, and after this is 
reached there is formed 
from within outward an 
opening, which becomes the 
sweat-pore. 

After birth these glands 
are found in all parts of 
the body, but in certain 
regions, such as the axilla?, 
the groins, the palms, the 

soles, and about the anus, the coil-glands are multiple, of unusual size, 
and often peculiarly arranged. They are specially numerous in the 
palms and soles, where, according to Krause, there are between two 
and three thousand to the square inch. 

Coil. — This part is a convoluted tube, of fairly uniform lumen, ter- 
minating in a csecal pouch, lined with nucleated cubical epithelia in 
a single layer of granular appearance, which are the secretory cells of 
the gland. Outside of the tube are smooth muscular fibres running 
parallel with or in a spiral direction about the coil. Surrounding 
both muscle-bundles and epithelium is a connective-tissue membrane. 
TJie glomerulus, or coil, is globular in outline and reddish yellow 




Coil of a sweat-gland ; S, tubule lined with 
cuboidal epithelia ; T, central calibre of the tubule ; 
D, beginning of the duct ; C, connective tissue with 
injected blood-vessels. Magnified 500 diameters. 
(After Heitzmann.) 



46 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

in color. In the larger glands irregular dilations and constrictions 
of the tube are conspicuous. 

Excretory Duct. — The excretory dud of the coil-gland passes from 
the glomerulus below to the epidermis above in a straighl or n spiral 
course. It is lined with a delicate hyaline cuticle (discovered by 
Heynold), beneath which is a double layer of cuboidal epithelium. 
Externally is a membrana propria, unprovided with muscular fibres. 
In outermost sheath is the usual connective-tissue layer. When the 
duct reaches the border-line of the epidermis, its inner cuticle and 
externa] connective-tisane sheath both arc Lost ; here it becomes a sweat- 
pore. It opens at time- within a hair-pouch. 

Sweat-pore.- Tin- i- a continuation of the excretory duct of the 
coil-gland after the I"— of it- cuticle and connective-tissue sheath. It 
i- the ]<>-- of these sheaths and the consequenl intimate relation "l" the 
canal t<> the epithelia of the epidermis that furnish the special basis 
for this distinction. The sweat-pore i- merely a wall-less canal or 
channel, spirally directed or running a straight course from the dud 
of the coil-gland below to the outer -t Btratum of the epidermis 



Sweat-pore traversing the epithelial layers <-i the -kin: /;/'. papilla with Injected 

t'l (-vessels; • . valley between two papilla*; /'. dud in iii«- rete mucosum ; / 

dermal layer; l'l.. coarsely granular epithelia, deeply Btained with carmine; /', <lu«t 

with corkscrew-windings in tin' epidermal layer. M - _ (After 

llMT/MANN.) 

above. It has no other wall than that formed by the cell- of the 
prickle-layer below and of the other layer- of the epidermis, which 
successively surround this canal, narrow below and funnel-shaped 
above. Eleidin-granules are found in the cell- which border the 
sweat-pore at a somewhat lower plane than the stratum granuloBUHL 
Hence the lumen of the sweat-pore, if such a term he permissihle. is 
in free communication with the juice-spaces of the epidermis. 

Secretion. — The secretion of the coil-glands consists largely of 



GLANDS. 



47 



globules of fat and grannies of pigment. The function of the coil- 
glands, therefore, is plainly the lubrication of the skin with unguent, 
a task performed only in small part by the sebaceous glands, and 
by them chiefly for the pilary covering of the body. The palms of 
the hands and the soles of the feet are thus lubricated with fat by 
the coil-glands. 

Fig. 19. 




Section of the skin from the palm of the hand (hardened in Moeller's fluid and 
treated with glacial acetic acid), magnified 300 diameters, showing epidermis and pars 
papillaris of the corinm traversed by the excretory duct of a coil-gland terminating in 
a sweat-pore : a, stratum corneum ; o'., its superficial layer, the cells in the upper and 
lower layers somewhat larger than those situated between the two ; b, stratum lucidum ; 
c, stratum granulosum ; d, stratum mucosum ; e, rete-pegs ; f, interpapillary process of 
rete meeting duct of coil-gland ; g, g, papilla? embraced by long prickles extending from 
lower palisade-layer of the rete ; ft, blood-vessels of papillae ; i, bundles of connective- 
tissue fibres of pars papillaris ; ft, section of spiral duct of coil-gland and sweat-pore. 



48 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

The total number of coil-glands in the body is estimated to be 
between two and three millions, and the total length of the uncoiled 
glands about eight miles. Those figures serve to give an approximate 
idea of their greal physiological importance, and of the extenl i<> 
which violation of the rules of hygiene possesses interest from a patho- 
logical point of view. 

The function of the sweat-pores which communicate directly 
with the excretory duets of the coil-glanda ia distinct from thai of the 
coil-glands, since it provides for the transmission outward of the 
watery fluids of the skin. The channel described as the sweat-pore 
lb in ample and (r<-c communication with the intercellular spaces of 
the epidermis; and ibis anatomical peculiarity provides fully for the 
needs of evaporation al the surface of the body. 

Tuna, following in the lines indicated by Meissner, asserts thai 
the coil-glands actually produce the subcutaneous fat-cushion. The 
coil-glands and the fat-cushion appear at the Bame period of foetal 
life and develop in the -nine proportions. At birth the clusters of 
fat are most conspicuous where the coil-glands are mosl numerous. 
In the adult the coil-glands are often Buhcutaneous in situation and 
closely Burrounded by fat-globules; while those glands which are nol 
found below the corium, though no1 thus Burrounded, are regularly 
met by columns of fal advancing toward them from below. 

The alternation of muscular fibres with the secretory cells of the 
ducts of the coil-glands is a provision for the extrusi f the gland- 
secretion onward. The same anatomical arrangemenl permit- free 
communication between the epithelia and the lymph-spaces which 
reach into the connective-tissue aheath of the gland. As a result, the 
lymph flows freely among the Becreting elements of the gland and 
its duet. This lymph, loaded with fat. streams away from the eoik, 
ami before it reach,- the lymphatic trunks i'- fat-globules are filtered 
away in the subcutaneous tissue. 

NAILS. 

Nail* are dense, elastic, and translucenl concavo-convex plates, of 

shells, of homy tissue, placed upon the dorsum of the terminal ex- 
tremities of the distal phalanges of the fingers and toe-. 'I hey 
result from an oblique invagination of embryonal epidermis, with 
modification of the keratinization-process at the level of the invagi- 
nation (Darier). Each nail ha- a free border at the distal portion 
of the pulp of the digit, with side- ami proximal borders let into dis- 
tinct furrows of the skin. The convex surface of the nail is ex: 
the concave, regarding the phalanx, is implanted upon the nail-bed 
beneath. 

In the embryo the first change looking to the formation of a nail 
consists in a peculiar smoothness and brilliancy of the epidermis cov- 
ering the dorsum of the distal phalanges. Later, an epithelial ridge 
or line, with a groove in front of it. traverses the tip of the finger. 
Thus, three regions are defined : the region behind the ridge, the nail- 



NAILS. 49 

wall ; that in the groove, the nail-bed ; and that in front of the groove, 
the pulp of the last phalanx of the digit. A group of large prickle- 
cells at the orifice of the nail-fold soon furnishes the first trace of the 
rudimentary nail. Mature nail-cells finally push forward between 
the prickle- and horny layers of the nail-bed, which, by fan-shaped 
bundles of follicles, is united firmly to the periosteum of the phalanx. 
Lastly, a thin plate of horny material with a free edge is visible ex- 
ternally in the fingers and toes of the newborn child. 

Matrix. — In the adult, what is termed the matrix of the nail is 
the tissue from which springs the horny plate. The cells of the 
matrix are cylindriform below and flattened superficially, with a 
fibrillary structure, and, instead of a stratum granulosum, are sup- 
plied with a layer of cells of brownish color charged with a keratog- 
enous substance. The matrix is separated into, first, a posterior 




Vertical section of one-half of nail and matrix : a, nail-substance ; ~b, horny layer ; 
c, mucous layer ; d, papillte of corium ; e, nail-furrow destitute of papillae ; f, horny 
layer of the ungual furrow rising above the nail ; g, papillae of skin of dorsal surface of 
the finger. 

part, filled with from three to six rows of papillae; and next, in 
advance of this, a lenticular space with curved borders, the anterior 
limit of which corresponds with the anterior border of the lunula. 
The area included in these two divisions is provided with papillae 
grouped in symmetrically converging ridges, decreasing in size as they 
pass forward. This forms the matrix of the nail. 

Nail-bed. — Further forward, the nail-bed proper — in other words 
the tissue that supports, rather than produces, the horny plate — -is 
composed of higher ridges of papillae, the grooves and summits of 
which are covered with prickle-cells, and the height of which is 
uniformly maintained as they stretch forward toward the pulp of 
the finger. 

Nail-fold. — The nail-fold, crescentic in shape, clasps the nail 
posteriorly and laterally. It is formed of connective tissue, the 
bundles of which are interpenetrated by numerous coil-glands and 
fat-columns. The epidermis beneath the nail exhibits prickle-, granu- 
lar, and horny layers. As the nail is gradually liberated from its bed 

4 



50 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

both at the sides and point the cornification of the horny layer be- 
comes more complete, so that finally, as the nail-plate is pushed for- 
ward, it no longer rides over the cells of the rete, but over a com- 
pletely cornified tissue. 

If the pulp of a nail-bearing phalanx be pressed with moderate 
force against any firm object, the naked eye can detect upon the 
surface of the nail, just behind its free border, a yellowish-white 
band, convex anteriorly and somewhat increasing in width laterally. 
This line is also visible when no pressure is exerted upon the digit, 
its widlh varying under the conditions described. This border repre- 
sents the space in which the three layers of the epidermis from the 
skin of the point of ihe finger, viz., the horny, the granular, and the 
prickle-layer, successively come in contacl with the under surface 
of the nail. 

Lunula.- — This is the relatively light-colored space extending from 
the middle part of the nail-fold posteriorly to its well-defined con- 
vex border in front. After artificial removal of the nail-fold the 
lunula is Been to extend to the posterior and enclosed border of the 
nail plate. It, therefore, represents thai part of the matrix of the 

Fig. 21. 




1 f%>k 



Implantation of a nail at its border: P, papllle decreasing in si/<- toward the mid- 
dle line: R. rete mucosum, which broadens toward the border of th<- nail, and forma 
Irregular prolongations; ir, i:. epidermal layer; If, plate of the nail. Magnified 500 
diameters. (Alter Heitzman.n.j 

nail not concealed by the nail-fold. Its color is not due to absence of 
vascularity, but is owing solely to the relative opacity of the kera- 
togenous cells which are concerned in the production of the horny 
threads that form the nail. 

Nail. — The nail ( True Nail, or Nail-plate) originates only from 
the floor of the nail-fold as far forward as the anterior edge of the 
lunula. As to its formation, it may, therefore, be imagined as spring- 



PHYSIOLOGY. 51 

ing from its matrix vertically in the form of an involuted, shield- 
shaped plate, its convexity regarding the proximal phalanx. It may 
then be viewed as pressed downward over its nail-bed in front, with 
partially unfolded edges enwrapped by the epidermis of the sides, the 
narrowed, point of the shield, elongated when untrimmed, projecting 
at some distance beyond the tip of the finger. 

With this conception it can readily be understood that the nail is 
constituted of horny filaments, or coherent strata of cornified cells, 
passing from the matrix or floor of the nail-fold. The upper surface 
of the nail grows, therefore, from the bottom of the nail-fold; the 
under surface, from the lunula ; and the intermediate layers propor- 
tionately from the parts between, that interlock with corresponding 
grooves on the upper face of the bed. 

Unlike the hairs, the growth of the nails, when not modified by 
traumatism or disease, is continuous and without definite limit dur- 
ing the life of the individual. The growth is from the matrix to the 
free border, more active in the young than in the old, and in sum- 
mer than in winter. From one hundred to one hundred and sixty 
days are required for reproduction of an entire finger-nail, and about 
three times that period for the nail of a toe. The uncut nail is pro- 
duced in the form of an elongated, pointed, claw-like talon. 

Nails are extremely sensitive to even moderate perversion of sys- 
temic nutrition; and either in loss of brilliancy and polish or in 
deeper structural alterations betray evidence of changes in the health 
of the individual. 

PHYSIOLOGY. 1 

The skin through its various component parts renders great ser- 
vice to the body as a whole through performing many physiological 
functions vital to life. Most important of these is protection, heat- 
regulation, secretion, sensation, and respiration, the last named only 
to a small degree. The skin is not simply an inert envelope in 
which the structures of the body are confined ; but is a living organ 
comparable in importance to the liver, kidneys, and other similar 
organs. 

Protection. — The epidermis is a poor conductor of electricity and 
light. In the tropics where the light is greatest, the natives are 
provided with an increased amount of epidermal pigment to screen 
them from the light. Inhabitants of the temperate zone, while visit- 
ing tropical countries require such clothing and shelter as will assist 
the epidermis in checking light penetration. 

The fatty matter in the stratum corneum prevents evaporation 
of the fluids of the body. The impermeability of the stratum cor- 
neum protects other organs of the body from the absorption of water 
and other fluids. Keratin is a substance which enjoys great power 

1 In the preparation of this chapter the following works were consulted : La 
Pratique Dermatologique, Tome L; Tigerstedt 's Physiology, 1905; Puhring, Cu- 
taneous Medicine, 1896, vol. I. 



52 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

of resistance to chemicals of all kinds. Resistance to micro-organisms 
which are normally present in the epidermis and to those also which 
are pathogenic that find accidental lodgment in the skin, is provided 
by the impenetrability of the corneous scales, their coherence, 
and the fatty matter present. The points offering least resistance 
to their entrance are the glandular orifices. In sweat-glands they 
are met by an acid secretion (the sweat) exuding from a narrow 
tortuous canal. The weakest point in the epidermis is the pilo- 
sebaceous system, where the Bebaceous secretion, which is pasty and 
fatty, offers some resistance. The fibrous corium by its strength 
and elasticity with the loose fat containing subcutaneous tissue, acts 
as an ideal support and protective apparatus against external injury 
of the delicate nerves with their special endings, the blood- and lymph- 
vessels, the glands, and hair-follicles of these regions. The brain lias 
:in extra protection through the abundanl hairy growth of the sculp. 

Heat-regulation.-- -In health the temperature of the blood ia main- 
tained at near a given poinl though the body be exposed to tempera- 
ture changes of wide variation. This is accomplished in the main by 
the Bkin through radiation, conduction, and evaporation. When the 
body is overheated, either from internal or external causes, the blood 
i< determined t" the Burface-capillaries with 1"— of heal by conduction 
and radiation; and at the same time increased activity of the <-"iI- 
glands i^ stimulated with outpouring <•( sweal which by evaporation 
dissipates such beat. When the body i- exposed t < . cm],], the cutaneous 
capillaries contract, Bweal Becretion is diminished or Btopped, and 
loss of heat i< thus prevented. In addition, heat-loss is lessened 
through contraction of the airectores pilorum which occurs when the 
body is chilled by le<-cniiiL r ,],,. , x | ,,,-,,., l cutaneous surface. The vaso- 
motor system regulating the blood supply is intimately concerned in 
the phenomena above described and apparently may acl by direct 
excitation from without (beat and cold) or reflexly from within by 
fever, hot drinks, shock, drags, i 

Secretion. — The Becretory function of the .-kin i- carried on 
chiefly by the Bebaceous and coil-glands. Their office ia to furnish 
oil and moisture to render the -kin Bofl and pliable and to a -mall 
degree, give off waste material. They play an important part in the 
body temperature. The sebaceous glands secrete in health greasy 
and oily matter (sebum I which ai. r part of the cutan- 

eous surface including the hairs. The palms and soles are not 
anointed by this secretion and they are the only parts which -how the 
effect of water even after prolonged immersion. In the glands, sebum 
is a fluid or semi-fluid substance which may be of firmer consistency 
in the ducts, and consists of proteid substances and chole-terin. 
The expulsion of sebum from the glands to the surface is accomplished 
largely by contraction of the arrectores pilorum muscles which sur- 
round the sebaceous-glands. 

Sweat is composed largely (98 or 99 per cent.) of water. It is 
colorless and has a specific gravity of 1003 to 1008. Its reaction may 



PHYSIOLOGY. 53 

be acid, alkaline, or neutral. It has an unpleasant odor and a salty 
taste. The odor varies according to the part of the body from which 
it is secreted. Under ordinary conditions it is acid but after profuse 
perspiration, its reaction becomes neutral or alkaline. The chem- 
ical composition of sweat is difficult to ascertain owing to the admix- 
ture with material from the sebaceous glands which necessarily cannot 
be eliminated. The quantity daily excreted is variable and depends 
largely on the requirements for heat-regulation. The amount in 
twenty-four hours is probably between a pint and a half and two 
pints. Urea is ordinarily present in very minute quantity but in 
certain pathological conditions, such as uremia, may become ap- 
preciable in amount. While the entire skin secretes sweat, cer- 
tain portions such as the brow, face and neck, axillss, genital regions, 
palms and soles are the chief areas of such activity. That there is a 
division of work in excreting water, between the skin and the kid- 
neys is shown by the light color of the urine in winter when 
perspiration is at a minimum, while the urine is heavy and darker 
in color in summer when the skin is actively secreting. The sweat 
secretion is influenced both by reflex and central stimulation. The 
secretion is increased by elevation of the external temperature, by 
copious warm draughts, by certain drugs such as pilocarpin, strych- 
nia, camphor, ammonia, etc., and such psychic phenomena as fright, 
anxiety, etc. It is diminished by external cold and such drugs as 
morphine and atropin, and in certain pathological conditions such as 
diabetes. The nervous centres for its regulation are located both in 
the medulla and spinal cord. The sweat-centres may be stimulated 
by venous blood caused by dyspnoea preceding death and reflexly by 
exciting the mucous membranes of the mouth with mustard and other 
condiments (Halliburton). While increased perspiration occurs as 
the result of vasomotor dilatation of the vessels in the skin due to 
heat or muscular activity, it may occur independently of this as is 
shown in the psychic causes mentioned. 

Sensation. — This function of the skin provides a means of pro- 
tection and discrimination. It was formerly thought that different 
sensations were awakened by varying degrees and kinds of irritation 
applied to a single nerve ending. Through the work of Blix (1833) 
and Goldschneider (1886), it is now known that there is a disassocia- 
tion of sensation. There are different nerve-endings for heat, for 
cold, for tactile sense, and for pain. 

Temperature Sense. — There are scattered over the surface of the 
body, certain points which convey only the sensation of cold, whether 
the irritation be electrical, mechanical, chemical, or by a hot or 
cold needle. There are other points which transmit only the sensa- 
tion of heat. Where the tactile sense is more acute, as in the hand, 
the temperature sense is diminished. The topographical areas of 
heat and cold must be studied from charts. 

Tactile Sense.. — This sense is not equally distributed over the sur- 
face of the body. It is keenest in the finger-tip and the point of the 



54 ANATOMY AND PHYSIOLOGY OF THE SKIN. 

tongue. It includes relative perception, with discriminations as to 
roughness, smoothness, hardness, softness, dryness, and moistness. 
Relative perception is often an accessory aid to vision. Pressure 
sense is often increased by the presence of hairs. 

Pain Sense. — Where the surface is denuded of epithelium, it is not 
apt to receive other sensation than that of pain. Pain too is ex- 
perienced from thermal, mechanical, chemical, or electrical irri- 
tation of severe character. There are nerve terminals which receive 
no other impression than that of pain. 

The nature of sensations of itching, tingling, and creeping has not 
yet been fully determined. 

Clinical observation suggests that one of the important factors in 
the production of itching is pressure on llie epidermis. Any inflam- 
matory or serous exudate occurring in jn-t the righl location to exert 
an outward pressure on the epidernii- will cause itching. If the 
exudate is more deeply Located, other sensations are experiencedi 
Tingling and creeping sensations are apt to denote deranged enerva- 
tion. 

Respiration.- — The respiratory activity of tin- Bkin depends <»n its 
permeability to gases and rapors in which function il i- accessory to 
the lungs. The manner in which this is accomplished is through ;t 
diffusion between the circulating blood in the capillaries and the 
atmosphere. Physiologically, oxygen is absorbed and some other 
gases. Water, carbonic acid i- r a-. and a trace of nitrogen are expelled. 
The respiratory function of the skin is far Less in man than in am- 
phibious animals (frog) whose -kin- are more Like a mucous mem- 
brane. The skin of these animals cannot be transplanted to man. 



II. GENERAL SYMPTOMATOLOGY. 



In cutaneous, as in other, diseases the clinical signs or symptoms 
of a morbid process are those by which a disease is recognized alike 
by the patient and the physician. These manifestations are divided 
into subjective and objective: the former are those appreciated by 
the patient alone in consequence of his sensations; the latter are 
those detected by the eye and the touch of another who undertakes the 
investigation of the disease. There are manifested to the eye and 
touch of the patient many objective signs which are liable to be 
interpreted or misinterpreted by him, with consequences not to be 
ignored. 

Symptoms of disease of the skin, may be manifested elsewhere 
than in the integument, as for example in the viscera. The relative 
importance of the symptoms in the one organ and the other differs 
greatly in different cases. 

SUBJECTIVE SYMPTOMS. 

The purely subjective symptoms of a disease of the skin are those 
manifested to the patient by sensations other than those connected 
with vision and his own sense of touch. They include sensations of 
itching, smarting, tickling, pricking, and burning; sensations as of 
increased or diminished susceptibility to the contact of foreign bodies ; 
of increased or diminished temperature; pain in various grades of 
severity; and disordered sensations, such as those suggesting the 
crawling of insects over the part, the passing of currents of hot or 
cold vapors or liquids, and the compression of portions of the skin 
as by cords, bands, or closely fitting plates. The character of the 
subjective sensations experienced by a patient often proves an aid to 
the physician in recognizing the nature, not merely of a present dis- 
ease, but also of one which has preceded. Thus, the sensation pro- 
duced by an attack of erysipelas is rarely an itching, while the latter 
is highly characteristic of eczema and scabies ; the pain of zoster and 
the tingling of urticaria being distinctly different, not only from 
each other, but also from the subjective symptoms named above. 

OBJECTIVE SYMPTOMS. 

The study of the objective symptoms of a cutaneous disease is of 
paramount importance. In no respect does the skilled physician so 
distinguish himself from one who is unskilled as in ability to recog- 
nize the typical or atypical objective features presented in diseases 

55 



56 GENERAL SYMPTOMATOLOGY. 

of the skin. This study is one which no diagnostician can safely 
neglect, and its rewards are precious in every department of medical 
science. These symptoms are spread before the eye, and their legi- 
bility increases with every hour of careful observation. 

These signs of skin-disease — or, more literally, skin-injury — are 
called "lesions" (efflorescences, elements of an eruption), and it is 
usual to classify them as primary and secondary. Such division, 
however, is open to criticism, since, in point of time merely, some of 
the so-called " primary lesions " of the skin become in turn secondary 
and even tertiary. Thus, a papule which mighl at one time be called 
" primary," may be transformed wholly or in part into a vesicle, 
which thus becomes a secondary lesion, and such vesicle again, in 
the evolution of a disease, may become a tertiary pustule, and the 
latter finally may result in a quaternary crust. In the following 
pages these symptoms of skin disease are distinguished as elementary 
and consecutive. 

ELEMENTARY LESIONS. 

In describing the average size of cutaneous lesions it i- Less 
convenient i<> Btate their measurement in fractions of a line or 
of a millimetre than to convey an approximate idea by comparison 
with familiar objects of relatively fixed dimensions. The « »1 . j « •< -t - 
usually selected for this purpose, beginning with the -mull' 
seeds of the poppy, mustard, and rape; the coffee-bean; the pea; 
the bean; the cherry; the finger-nail; the chestnut; the horse- 
chestnut; the egg of the hen and of ill'' goose; the orange. To 
these may also be added the point and head of a pin. The student 
will find it useful i<> familiarize himself with the size <>f the small 
seeds mentioned, thai their names may at once suggest to him the 
relative si/.' of the Lesions with which they are compared. 

Maculae. .Macula- {spots, stains; IV.. Taches; Ger., Heche) 
are generally circumscribed alterations in the color of the integu- 
ment, differing in size, shape, hue, and duration of the dyschromia, 
and unaccompanied by elevation or depression of the Bkin-surface. 

Macules may be congenita] or acquired: and may be the sole cu- 
taneous symptoms present in any case or be commingled with others. 
They may be transitory or permanent, few or numerous; as minute 
as a pin-point or a- extensive as the integument covering a limb. 

Macules may be due to arterial or venous hyperemia, to the 
escape of the coloring-matter of the blood into the skin, to acquired 
and congenital telangiectasis, and to pigment-anomalies. Examples 
of macules are to be found in the exanthematous rashes (measles) ; 
in localized hyperemia of the capillary plexuses of the corium, dis- 
appearing in various degrees according to the pressure exerted on the 
part (rosacea) ; in visible acquired development of blood-vese 
the skin (telangiectasis) ; in congenital vascularization of the surface 
(nsevi) ; in variously colored blood-extravasations and stases (pur- 
pura) ; in stains produced by contact with dyes (hand-workers in 



OBJECTIVE SYMPTOMS. 57 

anilin) ; and in pigmentary changes such as those produced by solar 
heat (freckles) or by leprosy. 

Extensive non-circumscribed changes in the skin-color are seen 
in the course of several general disturbances of the economy, as in 
yellow fever, cancer, chlorosis, albinism, Addison's disease, argyria, 
and icterus. 

Spots of various color and device are also produced by the in- 
tentional or accidental introduction of pigmented particles beneath 
the epidermis, as by the process of tattooing, the explosion of gun- 
powder, etc. 

Maculse exhibit a wide variation in color from a rosy pink to a 
chocolate brown or even a black. This difference has suggested the 
employment of such descriptive terms as roseola, erythema, and pur- 
pura, which, unfortunately, serve to distinguish both the features of 
diseases and the diseases themselves. 

A macula which encircles another lesion, as, for example, the 
halo around a vaccine vesicle, is called an " areola." Linear hemor- 
rhagic streaks are called " vibices " ; punctate and larger extravasa- 
tions of blood are termed " petechias " and " ecchymoses." 

Maculo-papules are elevated spots which approach the type of the 
papule. 

Papulae. — Papulae (papules; Ger., Knotchen) are solid or com- 
pressible, ephemeral or persistent, circumscribed projections from the 
surface of the skin, varying in size from that of a poppy-seed to that 
of a coffee-bean. 

These exceedingly common skin-symptoms vary greatly in their 
shape, color, location, career, and significance. Thus, they may be 
flattened at the apex, acuminate or pointed, conical, rounded, or de- 
pressed at the summit to form an umbilication ; they may be pale, 
rosy, dark or lurid red, purplish, or even blackish ; they may develop 
in transitory or persistent processes; they may be transformed into 
lesions containing fluids; may desiccate and furnish scales either 
at apex or base; may degenerate into ulcers; or may enlarge into 
tubercles or tumors; may be scratched, torn, or rubbed so as to lose 
their typical appearance; may come and go; may be sensitive to 
sudden changes in the blood-current, and yet be persistent. 

The mixed forms described above are generally named vesico- 
papular or papulo-vesicular, papulo-squamous, papulo-pustular les- 
ions, etc. 

Lesions which simulate the papule, and which, though described 
under that title, really belong to another category, are the small, 
semi-solid elevations of the surface that form at the orifices of the 
ducts of the cutaneous glands and follicles. Thus, they may consist 
of little heaps of epidermis about the hair-follicles (lichen pilaris, 
keratosis pilaris), or of inspissated sebum collected in one of, or in all 
the acini of the sebaceous glands (comedo) . 

The concomitants of an eruption of papular type also vary. 
Thus there may be a febrile process, or extensive infiltration of the 



58 GENERAL SYMPTOMATOLOGY. 

skin about and beneath the papules (prurigo), or itching of the most 
intolerable character (eczema papulosum), or production of trifling 
sensations of annoyance, as a slight burning without other subjective 
symptoms (acne, lichen planus). 

Papules transformed into moist lesions become covered with a 
crust. Papules scratched or torn by the finger-nails usually betray 
the fact in the minute and flat blood-scales dried upon their surface. 
Papules which ulcerate may be followed by scars, and those which 
have undergone the process of involution may be followed by macular 
sequelae. 

Pomphi. — Pomphi (urlicce, vjheals; Ger., Quaddeln; Fr., Plaques 
ortiees) are more or less transitory, pinkish, rosy red and whitish, 
irregular shaped and sized elevations of the surface of the skin, pro- 
duced by blood-stasis in spasm of the vessels, accompanied by a 
tingling or a prickling sensation, and characterized by rapidity of 
evolution and frequency of recurrence. 

The typical wheal is seen in the disease known as "nettle-rash " 
(urticaria), in which closely packed, Bhining, roundish, and whitish 
pea- to finger-nail-sized elevations of the -kin arc visible, surrounded 
by a slightly rosy border. Wheals are firm to the touch, and ar- 
ranged in patches, circles, bands, gyrations, or striations, often disap- 
pearing in a brief time and recurring with or without a renewal of 
the caiiN'. 'II"; lioned by a rapid exudation of Berum into 

the rete or pars papillaris of the corium. This is due to clonic vas- 
cular spasm, producing irregularities in the lumen of the skin-capil- 
laries, under the influence of the vasomotor nerves which supply 
a small area of the superior pars vascularis of the derma. The Ben 
sations produced arc Btinging, burning, prickling, and itching. 
Wheals are often surrounded by an areola. 

"Gianl "'-wheals are such as have the dimensions of a hen's egg, 
or cover extensive areas of integument, as, for example, the entire 
surface of a buttock or a shoulder. 

Relics of disappeared wheal- are usually transitory erythematous 
maculse, but in rare cases there is left a more or less deep pigmenta- 
tion which slowly disappears (urticaria pigmentosa). 

At times the whcal-likc condition is assumed by papilla?, as also 
by lesions resulting from guch traumatisms as the bites of insects, 
reptiles, ho] . etc. 

Tubercula. — Tubercula (tubercles, nodules; Ger.. Knoten) are 
circumscribed, solid, generally incompressible and persistent nodosi- 
ties of the skin, varying in size from that of a coffee-bean to that of 
a cherry. 

Tubercles occurring in diseases of the skin bear no relation 
to the lesions having the same name which develop in pulmonarv 
tuberculosis. The dermatological title relates chiefly to the size of 
the lesion. 

Tubercles may be projected largely from the free surface of the 
integument, or be deep seated in the skin, and but a small portion 



OBJECTIVE SYMPTOMS. 59 

become evident in the view externally. Their variations as to shape, 
color, size, slowness or rapidity of development, and other features 
correspond in great part with those described in connection with 
papules. They may be attached by a broad base to the skin, or be 
pedunculated, or even pendulous. Their seat is usually in the deeper 
portions of the corium or in the subcutaneous connective tissue. De- 
generating and ulcerating tubercles are followed, as might be sup- 
posed in view of their volume, by considerable destruction of tissue, 
and correspondingly in cases of repair by extensive cicatrices. Tu- 
bercles are seen in such diseases as fibroma, molluscum epitheliale, 
syphilis, leprosy, sarcoma, and cancer. 

Tubercles are often described as merely enlarged papules, but the 
distinction between these two forms of lesions will better be recog- 
nized when attention is paid to the particular portion of the skin in 
which each takes its origin. Many tubercles are pure neoplasms ; 
others may be hypertrophies. Papules spring oftenest from the 
superficial layers of the derma ; tubercles, from the deeper layers. At 
times a tubercle may project from the surface to a less extent than a 
papule, though its larger volume is evident as soon as the skin within 
which it has developed is handled. 

Tubercles due to a cellular infiltration may cease to be circum- 
scribed, and by coalescence furnish a diffuse involvement of both the 
skin and the subcutaneous tissue. 

Papulo-tubercles are transitional forms assignable to either of the 
two lesions named. 

Phymata.. — Phymata {tumores, tumors; Ger., Geschwulste; Pr., 
tumeurs) are masses of soft or solid tissue, or of solid tissue more 
or less commingled with fluids of variable consistency, differing 
in size, shape, color, and in the benignity or malignity of their 
career, located either within or beneath the skin, or, being attached 
to the skin, projecting from it to a variable extent. 

The mere fact that a lesion of the skin approaches in dimensions 
the size of a tumor is in itself an element of gravity. Tumors may 
originate in mere hyperplasia of the living matter; may consist of 
new formations of greater or lesser danger to the vicinage or to the 
general economy; may be formed of blood-vessels or of lymphatic 
vessels, or of both in the same lesion; may embody large fluid-con- 
taining cysts; may be built up of nerve-tissue, fat, bundles of con- 
nective-tissue fibres, glandular elements, and indeed of any of the 
elements which exist physiologically in the human integument. Tu- 
mors vary in size from a walnut to masses of enormous volume and 
weight. They may be pinkish, reddish, brownish, or even black in 
hue, and may be covered with a tense or flaccid extension of the 
integument. 

Examples of tumors are seen in fibroma, sarcoma, carcinoma, and 
rhinoscleroma. 

Vesiculse. — Vesiculse {vesicles, phlyctence, phlyctenules; Ger. 
Blaschen) are acuminate, rounded, or flattened elevations of the horny 



60 GENERAL SYMPTOMATOLOGY. 

layer of the epidermis with limpid, lactescent, or sanguinolent fluid 
contents, varying in size from that of a poppy-seed to that of a 
coffee-bean. 

Typical vesicles are seen in the minute, transitory lesions occur- 
ring in the vesicular form of eczema. They may be discrete, grouped, 
transitory, or for days persistent. They may be developed from 
papules. They are usually filled with a clear serum. Variations 
from this type, however, are common. Thus, they may be either 
flattened, acuminate, roundish, umbilicated, or conical ; may be fully 
distended or partially collapsed upon their contents ; may have a short 
or long duration; may be distended with a milky, chylous, or blood- 
stained fluid; may be opalescent, yellowish, reddish, or blackish in 
color ; several may coalesce to form a many-chambered bulla. One or 
several may undergo transformation into pustules or bulla\ Ves- 
icles may terminate by accidental or spontaneous rupture, their 
contents freely flowing forth upon the surface of the peripheral Integ- 
ument; or they may desiccate to a crusl : or may even terminate by 
one of the ulcerative processes. They may or may not be accom- 
panied by pruritus. Minute vesicles, which are merely the external 
apices of large-chambered accumulations of fluid beneath, occasionally 
form upon the surface of the .-kin. Such are Been in the course of 
lymphangiectasis. Vesico-pustules and vesico-bullse are intermediate 
forms of elementary Lesions represenl ing the types designated by these 
names. 

Pustulae. — Pustulse {pustules; Ger., Pusteln) are circumscribed 
cutaneous abscesses, covered with an epidermal roof-wall, and varying 
in size from that of a millet-seed to thai of a filbert 

The typical pustule contains pus, and is colored yellowish, yellow- 
ish-green, or brownish-green, according to the admixture of il 
tents with blood. The pus being an inflammatory product, aeo ssarily 
indicates the occurrence of an inflammatory process at the I 
the pustule. Pustule?, like vesicles, may be roundish, acuminate, 
globoid, conical, or umbilicated, and surrounded by an inflamed or 
normal integument : may be superficial or be deep-seated; may termi- 
nate by rupture or by desiccat ion : may or may not be followed by an 
nicer and ultimate cicatrix. They may be seated either upon the free 
surface of the skin, or at an orifice of a follicle, in which case they 
represent an inflammation with purulent product in the duct or the 
gland beneath. 

Pustules may originate as such, or i uence of transforma- 

tion of vesicles, or after a change in a papule, which may thus come to 
have a purulent apex. According to Auspitz, they invariably origi- 
nate from vesicles. Pustules often result in the formation of crusts, 
the latter varying in color according as the pustules from which they 
originated contained clear serum or blood. 

Transitional forms between vesicles and pustules and papules 
and pustules are termed, respectively, vesico-pustules and papulo- 
pustules. Pustules of a large size, resting upon an indurated, en- 
gorged, and elevated base are often called " ecthymatous." 



CONSECUTIVE LESIONS. 61 

Pustules are seen in syphilis, variola, eczema, scabies, acne, and 
many other cutaneous diseases, including several forms of dermatitis 
medicamentosa. Many contain pus-cocci ; some furnish a " neutral," 
or pseudo-pus destitute of micro-organisms. 

Bullae. — Bullae (blebs, " blisters " ; Ger., Blasen) are superficial or 
deep-seated elevations of the skin having fluid contents, differing in 
color, shape, and career, and varying in size from that of a coffee-bean 
to that of a goose-egg. 

Blebs have been described as large vesicles ; but this fails to define 
exactly their pathological character. Like vesicles, they may contain 
serum, lymph, blood, or pus, and may variously be colored according 
to the degrees in which their contents become visible through a semi- 
transparent roof-wall. They may be globoid, hemispherical, oval, 
crescentic, semi-crescentic, or conical, and may even exhibit angles. 
They may be seated upon an apparently unaltered or an evidently 
morbid integument ; and may or may not present a peripheral areola. 

Bullae may persist or may rupture ; may desiccate or may degener- 
ate into ulcers; may collapse after the escape of their contents, and 
the roof-wall become glued to the base from which it was originally 
raised. Bullae usually occur in extremely debilitated states of the 
system, and are, as a rule, of graver portent than other fluid-contain- 
ing lesions of the skin. They occur in scalds and burns, in pemphi- 
gus, leprosy, erysipelas, syphilis, and moist gangrene. 

CONSECUTIVE LESIONS. 

Squamae. — Squamae (scales; Fr., Squames; Ger., Schuppen) are 
attached or exfoliated epithelial lamellae which have become appre- 
ciable at the surface as the result of some morbid process in the skin. 

There is constantly in progress over the superficies of the body 
physiological desquamation, the evidences of which are not pro- 
nounced in skins properly cleansed by ablution. In morbid proc- 
esses, however, desquamation may occur as a distinct symptom in 
various forms. Thus, the scales may be minute, fine, branny, dirty 
white, or yellowish ; they may be large, pearly white, shining ; may be 
dry or fatty ; may be aggregated so as to resemble flaky pie-crust ; may 
exfoliate in extensive sheets, as from the entire sole of the foot or the 
palm of the hand, or in glove-finger-like sheaths, as from the surface 
of a digit; they may be scanty, scarcely perceptible, and so firmly 
attached as to require force for their removal; they may fall spon- 
taneously in a pulverulent shower, being so abundant as to encumber 
the garments or the bed-clothing of the patient. 

Furfuraceous or pityriasic desquamation is that form in which 
fine, bran-like scales are shed from the surface. 

Scales are frequently intermingled with other lesions, often suc- 
ceeding the latter. Thus a papule may scale at its apex, or surround 
its base with a collarette of loosened epidermal plates, beneath or 
between which a macular stain js visible. Again, scales may develop 



62 GENERAL SYMPTOMATOLOGY. 

from macule, tubercle, or tumor. Though generally conceded to be 
evidences of a dry and non-discharging disease of the skin, they are 
at times accompanied or succeeded by moisture of the part affected. 

The term scales is sometimes applied to the flattened plates of 
dried sebum that form on the scalp and on portions of the trunk in 
seborrhoea sicca. 

Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, 
and in several of the parasitic diseases of the skin. 

Crustae. — Crustae (crusts, "scabs"; Fr., Croutes; Ger., Krua- 
ten, Borken) are relics of the desiccation of pathological products of 
the skin. 

Crusts usually contain epithelial debris and scales, and may be 
compounded with loosened hairs and foreign particle-. Crusts never 
occur as primary Bymptoms of disease. When formed by the desic- 
cation of serum only, they are of a yellowish, straw-yellowish, or 
reddish-yellow hue; when composed largely of dried pus they are 
colored greenish or greenish-yellow; and when there has been an 
admixture of blood they are usually brownish or blackish. At times 
they suggest in appearance gum, honey, or Venice turpentine; in 
shape they may have ib" form of the concavo-convex lid of a watch- 
case; in color and shape they may resemble the half -shell of an oyster 
or the carapace of a small turtle. They may be delicate and thin, 
bulky and thick, friable or mealy; may be firmly attached to the sub- 
jacent tissues or readily separable; may cover a sound though tender 
and reddened epidermis; may conceal a superficial or a deep, foul- 
based nicer, by secretions from beneath which they are raised above 
the plane of the skin and increased in thickness ; they may be circum- 
scribed and no larger than a small finger-nail ; may envelop an entire 
limb or organ, as the leg or the penis; or. finally, may be so irregu- 
larly disposed among other lesions- papules, pustules, excoriations, 
and o| lr n nicer- that it is difficult to define their outline, or i 
ize their identity. Crusts formed of dried sebum are gn 
the touch, dirty yellowish in shade, and usually seated upon a non- 
infiltrated base. 

Crusts are common in eczema, Byphilis, leprosy, seborrhoea, and in 
a large number of other diseases of the integument. 

Excoriations. — Excoriations (obrai Ger., Hautdb- 

schurfungen) are superficial solutions of continuity, usually involv- 
ing portions of the skin affected with pruritus, and resulting from 
mechanical violence. 

Excoriations, in appearance among the mo-t trivial of skin-lesions, 
possess a value from the diagnostic point of view which can scarcely 
be overestimated. They occur as striated, linear, punctate, circular, 
or irregularly shaped, furrowed wonnds. at times involving areas of 
flat surface, oozing with serum or blood, covered with dried blood or 
crusts, yellowish, blackish, or reddish in line, and for the most part 
both induced and accompanied by severe pruritus. They may coexist 
with hyperemia and infiltration of the skin beneath, brought on by 



CONSECUTIVE LESIONS. 63 

the irritative character of the continuous, or, more frequently, inter- 
rupted, cause by which they were begotten. 

Excoriations become significant according as they indicate scratch- 
ing, tearing, or other species of wounding by the finger-nails, and the 
rubbing or piercing of portions of the integument with foreign bodies. 
In the former case they are significantly recognized in those portions 
of the body most accessible to the hands, though in the case of eczema- 
tous children and infarcts they may originate by the rubbing together 
of the knees, or the rubbing of one leg by the feet and toes of the other 
leg. The loss of tissue may extend deeper than the rete, at times 
invading the papillas of the corium, which bleed in consequence. 
Scars rarely result from any save the deepest excoriations. 

Excoriations may occur without the appearance of other lesions, 
as in the disease called " pruritus " ; but where itching is severe and 
induced by a cutaneous exanthem, the lesions constituting the latter 
may be intermingled with, obscured by, or even obliterated by excori- 
ations and the pathological processes to which they give origin. Thus, 
macules, vesicles, pustules, and papules may undergo change ; and the 
recognition of the type of the existing disease may correspondingly be 
difficult. Excoriations are common in skins wounded by lice, bed- 
bugs, and gnats ; in the subjects of eczema, scabies, intertrigo, and 
prurigo ; and in individuals with special sensitiveness of the integu- 
ment to the action of a medicament employed either internally or ex- 
ternally. 

Excoriations which occur after long-continued and persistent 
traumatism of the skin may be the seat of secondary infection with a 
purulent product, may become the seat of a severe inflammatory 
process, may be surrounded with a vivid halo of redness, may be 
seated upon a dense infiltration and may result in dense pigmentation 
of the skin. 

Rhagades. — Rhagades (fissures, cracks, rimoe; Ger., Hautshrun- 
den) are linear solutions of continuity, usually occurring in pre- 
viously infiltrated portions of the skin. 

Fissures may extend to the derma, and invade yet deeper struc- 
tures; may be painful or the reverse; may be dry, secretory, or in- 
crusted ; are often hemorrhagic ; and usually are formed with sharply 
cut walls. They are of frequent occurrence in the vicinity of the 
mucous outlets and articulations, in which situations they are induced 
or aggravated by movements stretching or tearing tissue the extensi- 
bility of which has been diminished by any morbid process. Eissures 
may terminate in ulceration ; they vary as to length, curve, and ten- 
derness; they are often exquisitely painful, and greatly complicate 
the skin-disease in which they form ; they may follow the curve traced 
by the boundaries of bodily organs near which they occur — as, for 
example, the line of the posterior junction of the ear with the head, or 
that of the breast of a woman with the thoracic wall upon which it 
rests. 

Fissures occur in eczema, syphilis, dermatitis, and lichen ruber. 



64 GENEBAL SYMPTOMATOLOGY. 

Ulcera, — Ulcera (ulcers; Ger., Geschwure) are losses of substance 
resulting from a previous pathological process involving the corium, 
and, in some cases, the subcutaneous tissue. 

Cutaneous ulcers differ greatly in size, shape, color, edges, base, 
career, and, indeed, in all their characteristics. Every ulcer has an 
outline, a base, a floor, edges, and a secretion. The outline may be 
circular, crescentic, reniform, ovoid, serpiginous, or with horseshoe- 
like contour. The base, or underlying tissue, may be soft, supple, 
indurated, or in a state of active inflammation, with consequent infil- 
tration. The floor may be glazed, shallow, deep, excavated, cup- or 
funnel-shaped, "worm-eaten," crateriform, sloughy, covered with a 
tenacious or a readily removed secretion, granular, puriform, or hem- 
orrhagic. The edges may be clean-cut, having a punched-out appear- 
ance, undermined, everted, ragged, irregular, or contracting, with a 
whitish inner border of advancing cicatrization. The secretion may 
be scanty, limpid, puriform. profuse, ichorous, and odorless, or exhale 
an offensive stench. Dicers may 1"- so crust-covered as to be invisible, 
or so exposed and erosive in action as to render the affected BUrface in 
the highest degree unsightly. They may be acute or chronic, insensi- 
tive or productive of intense pain ; may heal by cicatrization, remain 
open for a lifetime, or prove fatal either by destruction of parts 
tial to life or by exhaust ion of the vital forces. Ulcers may result as 
a consequence of a vast number of morbid processes, including trau- 
matisms, systemic affections (syphilis, leprosy, lupus, carcinoma), 
varicose veins of the lower extremities, hypostatic congestion (bed- 
Bores), and in cases of general debility with impaired resistance. 
Ulcers terminate after healing with cicatrization. 

Cicatrices. — Cicatrices (scars; Ger., Narbi n I are new-formed Bub- 
Btitutes for lost connective tissue. 

Scars never succeed excoriations, fissures, or other solution- of 
continuity in the skin that have not penetrated as far as the derma 

and resulted in destruction of ;i portion of the element- of which ihe 

derma is built up. They possess the highest importance f<»r the 
diagnostician. Bince they point invariably to a pathological process 

the career of which is terminated, the characteristic featui 
which termination they frequently embody. They may he regarded 

as ihe special and persistent imprints upon the integument, of the 
serious disorders from which it has suffered. 

To a certain extent, as already shown, scars retain trace- of the 
special peculiarities of the lesions, ami even of the diseases, which 
they succeed. The identification, however, of the individual prede- 
cessor in each instance is. in the present state of our knowledge, not 
always possible from a studv of cicatrices alone. The extent of 
knowledge in this direction, however, is rapidlv increasing: and in 
many cases the certainty thus acquired is of incalculable value to 
the diagnostician. 

Sears are remarkable for their tendency to contraction and grad- 
ual decoloration. They may be minute, punctate, extensive in area, 



UNCLASSIFIED LESIONS. 65 

attached to underlying tissues, depressed, raised above the plane of 
the peripheral skin, seamed with furrows, pliable and soft, indurated, 
traversed by ridges, knotted, or as irregular in contour as the ulcers 
already described. They may extend in digital, linear, or annular 
prolongations toward contiguous portions of the skin ; and by subse- 
quent contraction induce considerable distortion and deformity. 
Thus, they may drag down an eyelid, and ectropion ensue ; may glue 
the lobe of an ear to the cheek ; may evert lip or nostril. When recent 
they are usually reddish in tint ; when older they may be pigmented in 
centre or at circumference ; or, as is common, may exhibit a gradual 
decoloration centrifugal in progress. They may be the seat of 
pain from an entrapped nerve-filament ; may reopen to ulceration ; or 
may be unaccompanied by subjective sensation. Not rarely they 
become the source of keloid. Scars are unprovided with hairs, 
napillffi, or the orifices of sweat-pores and sebaceous gland-ducts. As 
implied in the definition given above, scars may result from any dis- 
ease or injury of the skin that involves loss of connective-tissue ele- 
ments in the corium. 

UNCLASSIFIED LESIONS. 

To the several lesions defined above Bazin adds, as elementary 
forms, the mucous patch of syphilis, the cuniculus, or furrow, 
produced in the skin by the Acarus scabiei, and the sulphur-colored 
crusts of favus. Among the elementary lesions of the skin, Brocq 
includes the gumma, or firm, deeply situated, often subcutaneous 
mass commonly degenerating centrally rather than, as may the 
tubercle, from without inwardly; while among the consecutive (so- 
called "secondary") lesions of the skin the same author considers 
" lichenization " or " lichenification." These are terms chiefly em- 
ployed by French writers to designate the changes in the skin pro- 
duced by long-continued external irritation, the thickened and in- 
filtrated integument assuming a yellowish-brown or reddish-brown 
tint, the exposed surface being studded with pinhead, pin-point, or 
slightly larger, shining and flattened isolated elevations, with delicate 
furrows separating each from the other. These, however, are not 
general, but special features of individual disorders, and are best 
studied in connection with the latter. 

The elementary lesions of the skin are termed by Auspitz anthe- 
mata; groups of such lesions, synanfhemata ; and, in accordance with 
common usage, generalized eruptions affecting the entire surface of 
the body, exanthemata. The word erythantJiemn is used to describe 
groups composed of several of the elementary lesions of the skin, as, 
for example, of papules, vesicles, and pustules, rising from a common 
reddened and hypersemic base. 

In addition to the names of the lesions of the skin just enumer- 
ated, certain peculiarities of cutaneous symptoms are described in 
qualifying terms which require definition. They relate chiefly to 
the color, shape, distribution, and method or period of evolution of 

5 



66 GENERAL SYMPTOMATOLOGY. 

lesions as they are observed in individual cases. The more important 
of these terms, as used by modern writers, are alphabetically arranged 
below, with a brief explanation appended to each. 

Abdominalis. Located on the abdominal surface. 

Acquisitus. Acquired. 

Acuminatus. Having a pointed apex. 

Acutus. Of acute course. 

Ami.toki'm. Occurring in adult years. 

.Kstivalis. Occurring in the Bommer season. 

Aggebgatus. Collected in patches. 

AGEIUS. Acute, or angry in appearance. 

Albidus. Of whitish color. 

A ngiectaticus. Vascularized. 

ANNULATUS; 1 T .. . 

ANNULARIS. J- 1 " th ° f0rm 0f a r '"^ 

Apyrkticus. Unaccompanied by fever. 

Areatus. Occurring in areas. 

Artificialis. Producible artificially. 

Asymmetrk'at.is. Of different distribution on the twolateral ha Ives of the body 

Autumnams. Occurring in the autumn. 

BfcACJ | curring on I of tlie arm. 

, '\ | ni ( n< oei m. Occurring in debilitated sub ■ 

Capitis. Occurring on the head, usually the scalp. 

Caveenosus. Large chambered. 

Chronicus. f 'lirmiip in course. 

CntorNATUS. Of circular outline. 

Ciboumsceiftus. Having a definite contour. 

■ 1 A 111 

iluens. f Arran g*d in close proximity, with coalese< i w i of lesions. 
Contagiosus. Capable of transmission by contagion. 
Corporis. Occurring on the surface of the body; employed usually to designate 

an eruption upon the trunk, as distinguished from thai on the head or the 

extn ii 
Crustosi-s. Croi 

Crystai.i.ints. Of crystalline appeanu 
Dcrrusus. Irregularly disposed. 
Disceeti B. Having isolated lesions. 

MiNvrrs. Disseminate; without regularity of distribution. 
Eeuption. Is ased of the totality of all patches and lesions upon the person of 

one individual. 
Erythematosus. Having a reddish Mush. 
Ksskxtiai.is. Idiopathic. 
KxK.n.iATivrs. Having s tendency to exfoliation or Bhedding of scales from the 

surface <>f the body. 
Exi Exhibiting lesions with a rficial ulceration. 

Facialis. Located on the face, usually as distinguished from the scalp. 
Favosa Displaying crusts of favus. 
Febrilis. Accompanied by a febrile process. 
Femoeaus. Occurring on the surface of the thigh. 
Fibrosis. Composed of fibrous tissue. 
Figurattjs. Having a figured appearance. 
Flavescens. Of yellowish hue. 
FotlACEDS. Resembling a leaf or leaves. 
Follicularis. Concerning the cutaneous follicles. 
Fungoides. Resembling a fungus. 

Fuefoeaceus. Exhibiting numerous fine, bran-like scales. 
Gtjttattjs. Of the size of a drop of water. 
GYEATUS. Having a serpiginous or gyrate outline, which is usually the result 

of a coalescence of imperfect circles or semicircles. 
Herpetiformis. Vesicular or herpetic in type. 
Hiemalis. Occurring in the winter season. 
Humidus. Accompanied by moisture. 
Hypertrophicus. Characterized by hypertrophy. 



UNCLASSIFIED LESIONS. 67 

Hystrix. Having lesions projected or erected like quills. 
Imbricatus. With crusts or scales overlaid like tiles. 
Impetiginodes. Pustular. 
Infantilis. Occurring in infancy. 
Intertinctus. Distinguished by color. 

Iris. Occurring in more or less distinctly defined concentric rings. 
Labialis. Occurring upon the surface of the lip. 
Lenticularis. Of the size of a small bean. 
Lividus. Deeply colored. 
Maculosus. Discolored. 
Madidans. Characterized by moisture. 
Marginatus. Having a defined margin. 

Medicamentosus. Produced by external or (more commonly) internal medi- 
cation. 
Melanodes. Of blackish color. 
Miliaris. Of the size of a millet-seed. 
Mitis. Of mild, benignant type — the reverse of agrius. 

Multiformis. Exhibiting simultaneously several types of elementary lesions. 
Neonatorum. Occurring in the newborn. 
Neuriticus. Having nervous association. 
Nigricans. Of a black or blackish color. 

Nodosus. With development of nodes or tuberosities of the surface. 
Nummularis. Of the size of small coins. 
Oleosus. Accompanied by an oily secretion. 
Palmaris. Occurring on the palms. 

p ' I Produced by an animal or a vegetable parasite. 

Patch. The aggregation of several isolated or confluent lesions. 

Phlegmonosus. Accompanied by deep-seated inflammation. 

Phlyct^noides. Characterized by groups of small vesicles. 

Pigmentosus. Accompanied by pigmentation. 

Pilaris. Eelated to the hair. 

Plantaris. Situated on the soles of the feet. 

Planus. Flat. 

Polymorphous. The Greek equivalent of the Latin multiform. 

Pr^putialis. Situated upon the prepuce. 

Progenitalis. Situated upon the exposed mucous surfaces of the genitalia. 

Pruriginosus. Accompanied by itching. 

Pubis. Located upon the skin or hairs of the pubes. 

Punctatus. Occurring in dots or points. 

Ehagadiformis. Fissured, or tending to produce fissures. 

Eosaceus. Having a rosy or pinkish hue. 

Euber. Eed; usually dark red in color. 

Scutiformis. Having the shape of a shield. 

Sebaceus. Concerning the sebaceous glands or their secretion. 

Senilis. Occurring in advanced years. 

Serpiginosus. Literally, creeping; advancing in irregular gyrations. 

Siccus. Dry; unaccompanied by moisture. 

Solitarius. Exhibiting an isolated lesion, or with isolated lesions. 

Symmetricalis. Similarly distributed on the two lateral halves of the body. 

Toxicus. Poisonous. 

Uniformis. Exhibiting lesions all of one type. 

Universalis. Affecting the entire surface of the body. 

Urticatus. Accompanied by wheals. 

Uterinus. With association of uterine disorder. 

Variegatus. Exhibiting several distinct colors. 

Vasculosus. Accompanied by vascular development. 

Vernalis. Occurring chiefly in the spring of the year. 

Versicolor. Exhibiting several shades of the same color. 

Vulgaris. Of the usual or commonly observed type. 



III. GENERAL ETIOLOGY. 



The study of the causes of skin-diseases gives a glimpse of the eti- 
ology of diseases in general. In the lowest representatives of life the 
greatest dangers to existence originate in exposure to assault from 
other and stronger representatives in search of their prey — in other 
terms, an external danger. In man, the highest representative of the 
animal scale, the perils of existence are complicated by his social 
necessities and his artificial methods. He can never, however, at any 
period of his existence, divest himself from the necessity of exposure 
to externa] peril. The plan of hia organs and the play of his normal 
activities arc perfect, even to the recovery from all but mortal injury 
and repair of moderate loss. The struggle for existence of the ideal 
man is intended to be with that which is without ; hia body meanwhile 
furnishing him with a comfortable tenement and a fair fortress. In 
the purview of nature there Bhould be no internal revolt. When Buch 
occurs it is usually the result of his ignorance, hi- folly, or his vice 

Viewed comprehensively the causes of diseases of the skin an 
to be numerous: extremely different from each other; some effective 
Bingly, others either alone or in combination with similar or different 
agencies; some operating -low] v. others rapidly; some operating from 
within the body, others from without: Borne directly, yet others only 
very indirectly, exerting their forces upon the integument. The re- 
sults ore as diverse as the causes them-' S >me dermatoses pro- 
duced by a single cause are similar in symptoms; other-, originating 
from like causi i I scarcely the slightest resemblance to each 
other. It is from a study of this interesting field that much of the 
experience of the diagnostician L8 derived. 

For convenience of classification, it is well to consider the <■-. 
of diseases of the skin: first. a= internal agencies; secondly, as exter- 
nal agencies: thirdly, as agencies which modify diseases produced by 
any of the original factors capable of their production. 

INTERNAL CAUSES. 

Heredity. — Some cutaneous disorders, such as syphilis, are cap- 
able of transmission to a second Generation. The prevalent doc- 
trines, however, respecting the inheritance of a large number of 
cutaneous affections are without question erroneous. Still the fact 
remains, that whether keratosis, psoriasis, and some other diseases 
not reeotrnizahle at hirth fas may he the lesions of syphilis), are at 
times the result of inheritance, it is certain that a predisposition to 
diseases of many kinds is perhaps in the majority of cases transmitted 



INTERNAL CAUSES. 69 

to a second generation. The weakness or vulnerability of a given 
organ of the body renders it especially liable to external or internal 
sources of damage, and may be strictly inherited. 

Sex and Age are not to be regarded as effective in the production 
of diseases of the skin, but some of the latter are conspicuously ex- 
hibited at certain periods of life, and others, in preponderance or 
exclusively, in individuals of one sex. Thus the several forms of 
rosacea are more common in middle life ; carcinoma in later years ; 
hydroa vacciniforme and contagious impetigo in children ; diseases of 
the nipple almost exclusively in women; and the trade dermatoses 
largely in men. 

Visceral and Constitutional Disorders. — The group of affections 
commonly included in the language of the schools as within the field 
of " inner medicine " furnishes a large list of causes effective in the 
production of cutaneous maladies. Among visceral disorders may be 
named those of the kidneys (Bright's disease, albuminuria, diabetes), 
giving rise to pruritus, angioneurotic oedema, eczema ; of the uterus, 
giving rise to certain pigmentary changes in the skin; of the central 
or peripheral nervous system, as in urticaria, herpes, hemiatrophia, 
pruritus, alopecia ; of the alimentary canal, producing eczema, acne, 
urticaria, etc. ; of the adrenals, as in morbus Addisonii ; and of the 
stomach, as in several of the gastric dyspepsias, which are capable of 
producing urticaria, erythema, acne, and rosacea. 

Among the constitutional affections capable of originating dis- 
orders of the skin may be named glycosuria (apart from renal dia- 
betes), which may be productive of glycosuric xanthoma; syphilis, 
which is responsible for an extended list of dermatoses; gout and 
rheumatism, which influence to a remarkable degree the oncoming of 
certain eczemas of the anal and other regions, multiform erythema, 
acne rosacea, and purpura; and disorders of the respiratory tract, 
some of which (e. g., asthma) are well known to have a distinct rela- 
tion to eczematous outbreaks, with which their attacks may alternate. 
Nervous System. — This may be responsible for a number of der- 
matoses. The nerve-centres, nerve-trunks, and nerve-terminals may 
largely influence inflammatory, congestive, and atrophic states ; cere- 
bral, spinal, and sympathetic nervous changes (trauma, new-growths, 
simple inflammatory thickenings, etc.) may be directly or indirectly 
concerned in attacks of pemphigus, zoster, scleroderma, urticaria, 
hyperidrosis, alopecia, and even grave ulceration of the skin. Pig- 
ment-changes in the skin and its accessories (hair and nails) have 
been produced by such causes- 
Psychical perturbations, as in the shock following traumatisms, 
terror, bereavement, great and prolonged anxiety, and even the ex- 
citements of success in war and business, have a demonstrable effect 
both on the nutrition and color of the skin and of the hairs and nails, 
as well as in the production of exanthemata, such as bullae, vesicles, 
and several types of dermatitis. In the same connection may be 
named the results of maternal impressions upon the foetus, which, 



70 GENEBAL ETIOLOGY. 

among the ignorant and to an extent also among men of science, are 
believed to be responsible for so-called " mother's marks," including 
pigmentary, papular, and vascular nsevi, as well as the larger lipoma- 
tous tumors associated with hairy moles. The disorders designated 
" hysterical neuroses " constitute a small group of affections occurring 
chiefly in young and hysterical women, characterized by the occur- 
rence of vesicular and bullous lesions, some taking on a gangrenous 
aspect, others exhibiting oddly arranged and defined streaks of derma- 
titis, to which latter the suspicion justly attaches that the lesions have 
been in great part produced by the patients themselves. 

Sexual System. — The sexual system of both men and women, es- 
pecially in young subjects, may be a source of cutaneous disorders. 
Among them may be named the seborrhceas, acnes, and comedones, 
often aggravated by menstruation and by perversion of function in 
both sexes, progenital and menstrual herpes, pemphigus virginum, 
and certain of the erythemata. The several cutaneous affections 
recognized in the pregnant condition are often unquestionably asso- 
ciated with the condition of the gravid uterus. Of these, t lie most 
common are Bcarlatiniform erythema, impetigo herpetiformis, derma- 
titis herpetiformis, and verrucas of the nilvar region. 

Auto-infection. — This i> a field of investigation the confines of 
which have been barely touched by the explorations of modern science. 
At present ii i- demonstrable merely that 1 1 1 » - alimentary tract, is tra- 
versed by innumerable micro-organisms which are wholly innocuous. 
Under certain favoring conditions, howevi r, these germs may either be 
commingled with others introduced from without, and thus become in 
various degrees dangerous i" the economy from slight perversion of 
health to actual destruction <<i life in ;i relatively brief period of 
time; or the innocuous parasites with ami without the cooperation of 
the toxins they engender, may suddenly become inimical to health 
from a change in condition. 

Ingesta. — Food and medicines are responsible for many cutaneous 
lesions in consequence, first, either of an inherent toxic quality in the 
substance ingested; or, Becondly, in consequence of a special irrita- 
bility of the alimentary canal existing at the time of such ingestion, 
the cause of the disorder being at other times ineffective. 

Among the foods capable of producing urticarial distress may be 
named shell-fish, the smaller berries having seeds, cheese, pickles, 
oatmeal, buckwheat, mushrooms, olive-, the ski: ds of grapes 

and of oranges, and certain kinds of fish, as well as alcoholic bever- 
ages. A large list of medicinal - - which are capable of pro- 
ducing skin-eruptions is enumerated in the chapter on Dermatitis 
Medicamentosa. Among these may be named, as illustrative of the 
group, the salts of bromine and of iodine, arsenic, quinine, copaiba, 
belladonna, and a number of the new remedies produced by the action 
of glacial acetic acid upon the petroleum-products, such as antifebrin 
and phenacetine. 

Physiological Crises. — These are not in themselves primary 



EXTEBNAL CAUSES. 71 

causes of dermatoses, seeing that the larger number of all members of 
the human family survive them without harm to the skin. It is none 
the less true that they furnish influences which modify and at times 
invite exanthemata. The possibilities of the pregnant state in con- 
nection with cutaneous disease have already been explained. Denti- 
tion is a period in which the child often is tormented by an eczema 
displayed in greatest profusion over the cheeks; and the puberal 
epoch of both sexes is one in which are manifested many of the dis- 
orders related to the repression, perversion, or excessive indulgence 
of the sexual function. Many of the chloasmata are conspicuous in 
women at the time of the menopause; and this also is a period in 
which may be recognized irregularities in the performance of the 
sweat-function as well as in the subjective sensations experienced in 
the skin. 

EXTERNAL CAUSES. 

Innumerable agencies operate from without capable of exciting or 
aggravating cutaneous affections: in fact, few if any of the forces 
operating externally upon the skin from the beginning to the end of 
life may not exert an unfavorable effect upon it if their operation be 
excessive, untimely, or associated with other externally operating 
factors.. Briefly, some of these agencies operate singly; others in 
cooperation ; some operate with grave, others with trifling effect ; some 
invariably, others but rarely, induce a deleterious effect upon the 
skin; some, though exerting an influence wholly external to the skin- 
surface, cooperate with internal agencies. In the latter class may be 
named the hand of the syphilitic subject, which may exhibit syphilo- 
dermata largely due to the influence of the articles handled in the 
trade or occupation of the subject of the disease. 

Scratching. — Scratching is a fruitful source of cutaneous trouble 
either when operating to originate or to aggravate an exanthem. Its 
symptoms are carefully studied by all diagnosticians, as they betray 
evidences of itching, which the efforts at scratching are exerted to 
alleviate. The regions most affected when scratching is severe (as in 
prurigo, scabies, pediculosis, and the forms of pruritus dependent 
upon visceral disease, such as glycosuria, tuberculosis of the adrenals, 
etc.) are, as a rule, those most readily reached by the hands either of 
an infant or an adult. In these parts may then be recognized excori- 
ations, frequently in two, three, or four parallel or approximated 
lines, blood-specks, pustules, papules, thickening, and even extreme 
induration and pigmentation of the skin, due solely to the trauma- 
tisms of the surface of the integument. 

Solar Light, Heat, and Thermal Changes (whether due to solar 
or artificial influence, as well as cold), are frequent and efficient 
sources of damage to the skin from the slightest grade of inflamma- 
tion to the severest destruction. To solar light is to be attributed the 
production of freckles, tan, and other pigmentations of the surface; 
to heat are to be attributed the erythema, the eczema, and the various 



72 GENERAL ETIOLOGY. 

grades of dermatitis which may follow exposure to the direct rays of 
the sun. Other temperature-effects, including those produced by 
extremes of both heat and cold, are to be classed in the same category. 
Exposure of the skin to a temperature of over 100° F. produces 
merely a transient erythema, which under a further elevation of sixty- 
five degrees will not subside for several days. At a temperature of 
212° F. all grades of acute dermatitis are awakened, with the produc- 
tion of bullae, up to the point at which complete destruction of the 
integument occurs. 

Seasons. — The influence of the seasons is of the same general 
character. Some cutaneous diseases are worse in summer; others in 
winter. 1 Prickly heat (lichen tropicus) is peculiar to certain warm 
seasons; frostbite, with its subsequent hypersemia, exudation, or gan- 
grene, occurs in winter; pruritus is common in cold weather; ery- 
thema multiforme is mosl frequent in the autumn and in the spring. 
X-rays. — Exposure of the skin to the x-rays, not merely in -(rul- 
ing skiagraphic results, but in the modern methods of treatment by 
radiotherapy, may produce slight or extremely grave changes in the 
skin and the structures beneath, including erythema, inflammation, 
telangiectases, atrophy, ulceration, and even carcinoma. 

Climate.- Climate has a determining influence upon many cuta- 
neous disorders, and this of a Bort which it i.- difficult to assign either 
to interna] or externa] influence. Thi i climate are exceed- 

ingly complex, and include the agencies which favorably or unfa- 
vorably affect the health in the direction of atmospheric humidity or 
dryness; abundance or scarcity of Bunlighl ; the prevalence of fa 
ing or injurious wind- and Btorms : a salubrious or insalubrious food- 
and water-supply; the average temperature of the earth's surface by 
day and by night; the presence or aba malarial 

plasmodia; and proximity to the sea, to mountain regions, or to 
tensive growths of pine forests. Thus leprosy, Lombanly erysipelas 
(pellagra), Biskra bouton, ainhum, and other affections, though m-t 
seen exclusively in one country, are for the most part prevalent in 
countries which may well be contrasted with others where such affec- 
tions are regarded as curiosities. Mycetoma, for example, has been 
studied for the most part in India, while less than half a dozen caa 
that disorder have been recognized in the Xorth American continent. 
Occupation. — Many den: due exclusively to the occupa- 

tions of men and women. In France, where such occupations are 
highly specialized on account of the artistic and skilled work of the 
people in numerous lines, these disorders are known as the " profes- 
sional dermatoses," and the diagnostician there is often enabled to 
decide the character of the work performed by the laborer on inspec- 
tion of his hands. The workers in dyes, in chemicals, and in drugs 
suffer in one way ; the men who handle tiles, bricks, mortar, or clay in 

1 Cf. Hyde, ' ' On Affections of the Skin Induced by Temperature "Variations in 
Cold Weather," Chicago Med. Jour, and Exam., 1885*, L, p. 1ST, and 1886, lii., p. 
116; Corlett, Jour. Cutan. Dis., 1S94, xii., p. 457, and Jour. Amer. Med. Assoc, 
1902, xxrix, p. 15S3. 



EXTERNAL CAUSES. 73 

another; the baker, the confectioner, the cook, the laundress, the 
green-grocer, the seamstress, the shoemaker, the carpenter, and the 
machinist have each their forms of erythema, dermatitis, keratosis, or 
induration. Similarly those whose faces are much exposed, as the 
wheelmen of vessels, tramcar-drivers, locomotive-engineers, and day- 
laborers, exhibit symptoms in that region. Butchers, wool-workers, 
cattle-men, and sheep-shearers are liable to contract glanders, ring- 
worm, or malignant pustule. They who handle the bodies of the dead 
are prone to tuberculosis of the hands (anatomical tubercle), and 
those compelled to stand much of the time are exposed to the conse- 
quences of varicose veins of the legs and resulting eczema of that region. 

Clothing. — The coarse clothing worn by the poorer classes is 
often a source of skin-mischief, particularly when employed for in- 
fants ; and persons of both sexes and all ages exhibit marked results 
from the wearing of flannel next the skin. Often the influence of 
clothing is commingled with that of dyes, as when brightly tinted 
flannel colored with anilin produces a dermatitis of high grade with 
distinct staining of the skin over which such clothing has been worn. 
In the same list must be included the effects produced by ill-fitting 
shoes, corsets, trusses, napkins, " pads," supporters, crutches, ortho- 
paedic apparatus, hat-bands, stockings, garters, and chest-protectors. 
Here, too, more than one cause may be efficient in the production of 
disease, as when clothing becomes a nidus for parasites, or is worn 
next the skin when soiled with abnormal or even physiological se- 
cretions. 

Irritation. — Chemical, medicinal, and mechanical irritation may 
be responsible for many affections of the integument. Of articles 
effective in the first category, may be named the stronger acids and 
alkalies; of those in the second class, arnica, croton-oil, mustard, 
cowhage; of those in the last class may be suggested all substances 
capable of exerting undue friction upon the surface, such as pumice- 
stone, combs, brushes, towels, and the articles employed in the opera- 
tions of the manicure. 

Filth. — Filth is a potent factor in both the production and the 
aggravation of skin-disease, its effects being decidedly most apparent 
in patients applying to the public dispensaries. In infants the skin 
unwashed even for a fortnight usually becomes the seat of an irri- 
tating urticaria. 

Traumatism. — Traumatism plays a most important part in cutan- 
eous etiology. It includes the action in scratching, with the nails, of 
the knees, heels, elbows, etc., as well as the influence of articles used 
for the same purpose — pieces of cloth of various kinds, etc. In this 
way excoriations and even infiltrations, of the skin are induced. 
Under the head of traumatisms should be considered also injuries of 
the skin-surface produced by animals, occasionally with the added 
effect of a toxicant. Here are included the wounds produced by 
lice, fleas, bugs, and acari; the bites of serpents, horses, dogs, and 
cats; and the accidents producing traumatism of every kind, not 



74 GENERAL ETIOLOGY. 

omitting the intentional wounds inflicted by the surgeon and their 
results. 

Transmission by Contagion, by Infection, and by Parasites. — 
Some disorders with cutaneous phenomena are transmissible from 
diseased to healthy persons through the medium of the atmosphere, 
and are termed contagious; others are termed infectious when trans- 
missible solely by contact. Some maladies, such as variola, scarla- 
tina, and measles, arc conveyed by both methods, and hence belong to 
the category of both contagious and infectious disorders. Yet others 
are transmissible only through infection with a specific virus; such 
diseases are syphilis and lepra. By many writers the terms infec- 
tious and contagious are used as synonyms. 

Many disorders are transmitted by the medium of insects (par- 
ticularly the fly, the bed-bug, the louse, the flea, and the mosquito), 
which attack the skin and deposit in the solutions of continuity which 
they produce, bacteria or other noxious germs derived from foreign 
bodies on which they previously have alighted. 

Parasitic Diseases. Under this title were once included solely the 
dermatoses induced by the presence of the animal and vegetable para- 
sites. Anion- the former may be named Bcabies and pediculosis; 
among the latter, ringworm of the scalp and of the heard. Bui the 
term parasite has acquired a much wider Bcope since the recognition 
of the micro-organisms which have been demonstrated to be efficient 
in the production of a long li-t of cutaneous affections. Among these 
may be named the bacilli productive of cutaneous tuberculosis and of 
lepra : ihe pus-cocci, responsible for the Beveral forms of impetigo and 
pustular eczema; and the streptococci, recognized in several forms of 
dermatitis. In most of the dermatoses which are recorded to-day as 
parasitic, germs have been recognized, which either singly or in co- 
operation with others have been proved to be effective in the produc- 
tion of these disorders, or have been demonstrated to play an active 
pari in either tin ir extension or exacerbation. 

The popular idea- respecting the frequency and danger of con- 
tagion in diseases of the -kin are often erron< ous. The non-parasitic 
affections are. and probably always will he. more numerous than all 
others. The danger of communicating Bcabies, syphilis, and other 
affections by handshaking is no1 a- great a- i- generally believed. On 
the other hand, the dangers which by the mass of people are little 
considered are often the graver and more to be avoided. Among these 
may be named the use in public of the roller-towel, the drinking in 
common from public cups and glasses, promiscuous ki.-sing, contact 
with the lower animals exhibiting diseases of the hide, of fur. or of 
feathers, the wearing of a stocking on one foot which the day before 
was worn over the surface of a fellow-member the seat of d i 
and the wearing of velvet- or fur-trimmed collars on top-coats after 
the occurrence of a disease of the skin of that part of the neck w T ith 
which the garment is naturally brought into contact. 



IV. GENERAL PATHOLOGY. 1 



The pathological processes occurring in the skin are similar in 
many diseases to those occurring in other organs ; but owing to com- 
plicated structure and functions the integument has a pathology pecu- 
liar to itself. Various pathological conditions, such as inflammation, 
hyperemia, anaemia, hypertrophy, atrophy, degeneration, and neo- 
plasms, are found in the skin, as in other organs of the body. Some 
diseases, such as the toxic erythemas, are merely cutaneous manifesta- 
tions of an internal disorder which often exhibits no demonstrable 
internal lesions; in others, such as lupus vulgaris, the pathological 
and clinical manifestations are for the most part limited to the skin. 
Again, in diseases such as syphilis similar pathological changes may 
be noted both in the internal organs and in the skin. 

Bacteria. — The skin furnishes a habitat for a large number of 
bacteria, both pathogenic and non-pathogenic. From the normal skin 
may be collected a number of varieties of cocci, bacilli, and yeasts. 
Many diseases of the skin are demonstrably of bacterial origin, while 
others are probably due to specific micro-organisms not yet recognized. 
Schizomycetes (tuberculosis, leprosy), streptotricheae (actinomyco- 
sis), blastomycetes (blastomycosis cutanea), hyphomycetes (favus, 
"ringworm"), are all concerned in the production of diseases in the 
skin or its appendages. Animal parasites are responsible for several 
disorders (scabies, pediculosis). 

Hyperemia. — Hyperemia in the skin may be active or passive, 
local or general, transient or persistent. On account of the conditions 
which may be associated with hypersemia it plays an important part 
both in cutaneous and general pathology. Galloway has emphasized 
the importance of erythema as an indicator of disease. 2 

Ansemia. — Anaemia may be general or local. It is not a frequent 
factor in the production of cutaneous disease. Generalized anaemia is 
a symptom of several diseases of the blood. Local anaemia occurs in 
Raynaud's disease. Local, transient anaemia occurs in urticaria and 
when cold is applied to the integument. 

Inflammation. — Some of the many phases and pathological 
changes of the process recognized as inflammation are present in the 
majority of cutaneous diseases. Primarily, there occurs vascular 
dilatation, with leukocytic infiltration and exudation of plasma. The 
leukocytes, attracted by positive chemotaxis to the point of irritation, 

1 For a complete presentation of the subject of the pathology of the skin, see 
Unna, Histopathology; Darier, La Pratique Dermatologique, pp. 67-136; MacLeod, 
Pathology of the Skin. 

2 Brit. Jour. Derm., 1903, xv., p. 235. 

75 



76 GENERAL PATHOLOGY. 

either remove the offending material, micro-organisms, etc., by phago- 
cytic action, or themselves are overcome, undergo fatty degeneration, 
and become converted into pus-cells. The chemotactic agent may be 
a mechanical, chemical, or thermic irritant, or its cellular products. 
The toxins of micro-organisms may be effective. The plasma dilutes 
the toxins, and by depositing fibrin through the action of a ferment 
helps limit the process. Varying with the degree of the reaction and 
its attendant conditions, numerous secondary epidermal changes occur. 

Histology. — The epidermis and corium, being unlike in develop- 
ment and structure, undergo different pathological changes. 

The epidermis is composed of epithelial cells in various stages of 
evolution, from the columnar, nucleated, and comparatively highly 
differentiated cell of the basal layer of the rete mucosum, to the flat 
and lifeless external cells of the stratum corneum. A knowledge of 
the normal process of evolution of these cells is necessary to an under- 
standing of the changes which necessarily must occur in morbid con- 
ditions when the norma] course of evolution is interrupted by some 
mechanical, chemical, microbic, or other agency. Each cell progresses 
from the basal layer of the rete through the several strata above until 
it reaches the superficial part of the stratum corneum. having on its 
way passed through various stages, and performed different functions. 
After completing its cycle of existence it is finally cast off. 

In the basal layer are situated the mother-cells of the epidermis. 
They are columnar in shape, contain nuclei ami pigment, receive the 
termination of non-medullated nerve-fibrils, and have extending from 
them prolongations of protoplasm called prickles. A- they progress 
upward through the rete tiny become gradually flattened, no longer 
contain pigmenl (in the while races), and on reaching the granular 
layer are filled with granules of keratohyalin, upon the perfect for- 
mation of which depends the normal process of cornification. Further 
up, the cells become homogeneous and lose their keratohyalin, but 
acquire elei'din in the stratum lucidum. In the lower part of the 
stratum corneum their nuclei disappear and a horny substance, 
termed keratin, is formed, to which substance this layer owes its 
hardness. Here also some fat appears. Still more externally, the 
cells become entirely flat and lifeless, and eventually are shed. 

Hyperkeratosis — Acanthosis. — One or all of the layers of the 
epidermis may be involved in pathological processes depending upon 
the character of the change and its cause. When there is overgrowth 
(hypertrophy), either local or generalized, of the stratum corneum, it 
is designated as a hyperkeratosis, examples of which are seen in 
keratodermia and ichthyosis. 

By acanthosis (Unna) is meant a benign hypertrophy of the rete, 
in which the fibrillary structure of the cell is retained. Acanthosis 
occurs in all the infective granulomata, including syphilis and tuber- 
culosis. Malignant hypertrophy of the rete occurs in epithelioma, in 
which affection the normal rete-pegs not only are enlarged and elon- 
gated (acanthosis), but there are also rupture of the basal layer and 



PATHOLOGY. 77 

irregular infiltration into the corium, of epithelial cells, which lose 
their fibrillary structure and often become so changed as to resemble 
cells of mesoblastic origin. 

Atrophy. — Atrophy of the cells of the epidermis occurs under var- 
ious conditions. It may be caused by pressure, either external, as 
from a truss; or internal (neoplasm beneath the skin). It is found 
commonly in the senile skin, and is marked in cases of diffuse idio- 
pathic atrophy of the skin. 

Parakeratosis, Production of Vesicles, Bullae, and Pustules. — 
(Edema occurring in and between the rete-cells interferes with the 
formation of keratohyalin in the granular layer, causes the cells of 
the stratum corneum to appear swollen and moist and to retain 
their nuclei, and prevents the formation of keratin. This condi- 
tion is termed " parakeratosis " (Unna) , and is found in typical 
development in eczema and psoriasis. When the oedema becomes 
greater, collections of fluid form usually in the rete, and thus vesicles 
are produced. They are called "parenchymatous" when the early 
oedema is intracellular, or " interstitial " if it be intercellular. Ves- 
icles may be located superficially in the rete, as they usually are in 
eczema ; or deeper, as in dermatitis herpetiformis ; or beneath the 
epidermis, as occasionally happens in herpes zoster. Vesicle-forma- 
tion is dependent not only on the mechanical separation of the cells 
by oedema, but also upon the presence of toxic and other substances 
in the lymph, which may produce separation and disintegration 
of the epithelial cells, and thus leave spaces. Bullae similarly are 
formed and located, and differ from vesicles chiefly in being larger. 
A typical bullous disease is pemphigus. When a large number of 
leukocytes collected in a chamber by chemotactic or other action, 
have undergone fatty degeneration, the lesion becomes a pustule. 
When oedema is long persistent, such as occurs when the leg is the 
seat of varicose veins, the epidermis is destroyed entirely and ul- 
ceration results. 

Epithelial Degeneration.- — The cells of the epidermis are subject 
to degenerative processes, the one most studied being of the " hyaline " 
type. This occurs in carcinoma and also in several other diseases, but 
is not, as once was believed, pathognomonic (see cellular degenerations 
of the corium). Degeneration occurring in epithelial cells exposed to 
x-rays, though not definitely classified, is pronounced and important. 
The nucleus as well as the cellular protoplasm is affected. The cell is 
swollen, stains poorly, becomes vacuolated, and eventually completely 
disintegrates and is carried away by leucocytic action during the 
period of reaction. 1 

Fibrous and Cellular Structure of the Corium. — The corium is 
mesoblastic in origin, and is composed of fibrous tissue and cellular 
elements. The white fibrous bundles are termed collagen, while the 
yellow elastic fibres are termed elastin. The cells found normally 

1 Scholtz, Arciiiv, 1902, lix., pp. 87 and 241 (abstr. in Brit. Jour. Derm., 1902, 
xiv., p. 397). 



78 GENERAL PATHOLOGY. 

in the corium are connective-tissue, mast-, and vacuolated cells. As 
cellular pathology is so important in cutaneous disease, some knowl- 
edge of the minute structure of normal and pathological cells is 
essential. 

The common types of connective-tissue cell are large, spindle- 
shaped cells, which vary both as to size and shape. They have extend- 
ing processes, which connect with those of neighboring cells. The 
nucleus is surrounded by a membrane, is usually either oval or round 
in shape, and is said to be vesicular on account of its open appearance, 
which is due to large spaces found between the chromatin threads. 
This open structure causes it to stain less deeply than the more com- 
pact nucleus of the mononuclear leukocyte, with which it often is 
confounded. In young connective tissue the cells are small and more 
or less oval, have a nucleus as above described, are Burrounded by cell- 
protoplasm, and are termed fibroblasts. Other and less common va- 
rieties of connective-tissue cells are described by Unna as plate-cells. 

Vacuolated cells of the corium Line nuclei similar to those of 
ordinary connective-tissue cells. The cell-protoplasm presents spaces 
or vacuoles, bu1 has no processes extending from it. On account of 
mitoses occurring in these cells, and because their apparenl function 
is thai <>f reproduction and nol of evolution into connective lissue, 
MacLeod suggests thai these may be the mother-cells of the corium, 
being thus analogous to the cell- of the basal layer of the epidermis. 

Mast-cells in tin- corium resemble other connective-tissue cells, bul 
differ from them in thai they contain :i number of basophilic granules. 
They are discussed more fully in connection with the pathological 
cells of the corium. 

Pathological Cells of the Corium. -Plasma-cells. Before CTnna 
described the cell now generally recognized as the plasma-cell, :it leasl 
two classes of cell- were bo denominated. The term is now r< stricted 
to cells which vary in Bize from that «»f n leucocyte to thai of b cell 
two or three times BS large. They are rounded or oval in shape :uid 
contain a large amount of protoplasm. The nucleus i- usually eccen- 
trically placed and corresponds in Bhape to that of the cell. It may 
he vesicular in appearance, or again several deeply stained ma 
chromatin may be arranged about if< border. Two nuclei are occa- 
sionally present. A cell having n similar nucleus, but containing a 
small amount of protoplasm, is found abundantly in tuberculosis, bn1 
is considered by many to be a lymphocyte. Plasma-cells are found 
abundantly in the infective granulomata. and to these cellular infil- 
trations Unna applied the term granuloma. TJnna maintains that 
plasma-cells originate from connective -tissue cells, while Jadassohn, 
Councilman, Krompecher, Schottlander-Vmarschalko, and others be- 
lieve that they arise from leukocytes. Krompecher, Vmarschalko. and 
others agree that these cells evolve into connective tissue, thus admit- 
ting the formation of connective tissue from leukocytes. 1 Plasma- 

1 For full consideration of the cells of chronic inflammation, including plasma- 
cells and mast-cells, the reader is referred to a critical review of the literature by 



PATHOLOGY. 79 

cells are studied best when stained with polychrome-methylene-blue 
(TJnna), or Pappenheim's compound stain of pyronin-methyl-green. 
In the former, metachromatism is shown by the nucleus taking a blue 
color, while the protoplasm is stained a blue violet. 

Giant-cells occur in typical development in tuberculosis, but are 
found to a degree in syphilis, and cells resembling them may be 
noted in several chronic inflammatory diseases of the skin. The 
tubercular giant-cell may be round, oval, or irregular in shape, 
depending somewhat , on its surroundings, as, for example, the 
presence of collagen, elastin, etc. They vary in size from two or 
three to many times the dimensions of a leukocyte. They contain 
nuclei which are similar to those of plasma-cells ; and which may be 
arranged at one or both ends or sides, or completely round the periph- 
ery of the cell, and may number from a dozen or less to more than a 
hundred in a single cell. They stain deeply, thus making a contrast 
with the poorly stained centre of the cell, which presents a homo- 
geneous protoplasm. As to their origin, several theories are ad- 
vanced. One is that they are formed by the rapid proliferation of the 
nuclei in a single cell without corresponding division of the proto- 
plasm. A second is that a number of cells surround some irritant, 
such as tubercle-bacilli, and coalesce, thus producing the multinu- 
cleated giant-cell. The question whether the giant-cell originally 
comes from connective-tissue cells or from leukocytes cannot be 
answered until the origin of the plasma-cell has been determined. 

Mast-cells occur to some extent in the normal corium, and are 
found in increased numbers in some diseases, including the infec- 
tive granulomata, in which they are not specially significant. In 
urticaria pigmentosa, however, their increase is so marked as to be 
pathognomonic. They may be produced rapidly, as was demonstrated 
by Gilchrist, 1 who noted that they formed synchronously with an urti- 
carial wheal. They may assume the shape of a connective-tissue cell, 
plasma-cell, or lymphocyte, and may originate apparently from any 
cell found in the corium. Their chief characteristic is the presence 
of basophilic granules in the protoplasm. Mast-cells of the corium 
correspond in staining reactions to Ehrlich's mast-cells of the blood, 
but it does not follow that those present in the cutis come from the 
blood. They are demonstrated best by stains having metachromatic 
properties, such as polychrome-methylene-blue (TJnna), which stains 
the nucleus blue and the granules red. 

Degenerations Occurring in the Corium. — Hyaline degeneration 
similar to that occurring in epithelial cells in carcinoma is found also 
in the corium in sarcoma, in rhinoscleroma, in syphilis, and in other 
affections. It produces a homogeneous material in the cellular proto- 
plasm, which is acidophilic in reaction and, owing to its semifluid 

Williams, Amer. Jour. Med. Sei., 1900, cxix., p. 702; a series of papers by Pappen- 
heim, and by Almkvist, Monatshefte, 1901-2; Maximow's monograph, Ziegler's 
Beitrage, Suppl. v., 1902; and a review of the subject by Whitfield, Brit. Jour. 
Derm., 1904, xvi.„ pp. 7 and 63. 

1 Johns Hopkins Hosp. Bull., 1896, vii., p. 140, 



80 GENEBAL PATHOLOGY. 

character, forms round globules. Hyalin is stained orange-red by 
Van Gieson's method. 

Tatty Degeneration occurs in several conditions in the skin, and 
is well represented in xanthoma. Here are found variously sized 
granules within a large cell, known as the xanthoma-cell, which is 
characteristic histologically of the disease. This cell is the product of 
a connective-tissue cell in the multiplex varieties, while, according to 
Pollitzer, 1 in eyelid xanthoma it results from degeneration of mus- 
cular tissue. 

Mucoid Degeneration is found in the " Mikulicz cells " of rhino- 
scleroma and in the lepra-cell of lepra. In both it occurs as a homo- 
geneous mass, within which the specific bacilli are found. 

(Edematous Degeneration occurs in the cells of the corium. which 
is the seat of marked oedema. They appear swollen, slain poorly, and 
contain fluid. This form of degeneration is seen in tissue reacting 
after exposure to actinic and Rontgen rays, 

Crenation-degeneration is found in mycosis fungoides, and is evi- 
denced by the coll becoming irregular and toothed. Eventually the 
cell entirely disintegrates. 

In addition to the cellular degenerations described above, several 
degenerative processes occur which affect the collagen and elastin. 

Myxomatous Degeneration, in which a peculiar jelly-like Bubstance 
containing mucin results from collagenous degeneration, is found in 
sarcoma and myxedema. This substance is basophilic in reaction 
and is stained by any of the metachromatic dy< 

Colloid Degeneration in the skin Is comparatively rare. It occurs 
in the disease termed colloid milium. It consists of a homogeneous 
degeneration of the fibrous elements of the corium. The exact chem- 
ical composition of the colloid material is not known. It is stained 
yellowish-red by Van Gieson's method. 

Other degenerations occur in the corium, in which collagen and 
elastin are concerned, and these are demonstrated chiefly by the 
staining methods described by Unna, 2 and are termed basophilic 
collagen, collastin, collacin, and elascin. 

1 Jour. Cutan. Dis., 1897, xv., p. 867; N. Y. Med. Jour., 1897, lxv., p. 679. 
* Monatshef te, 1894, xix., p. 465. 



V. GENEEAL DIAGNOSIS. 



The establishment of an accurate diagnosis in cutaneous diseases 
is essential to their successful management. This statement is ren- 
dered necessary in this connection by the prevalence of a belief 
among the uneducated that the disorders of the skin, exhibited for 
the most part in visible symptoms, can safely be treated on general 
principles without a recognition of the nature of the malady. By 
many practitioners the demand for an accurate diagnosis is ignored 
in consequence of a too general impression that the desired end is to be 
pursued through great and perplexing obscurity. Yet with patience, 
method, a habit of careful observation (without which no physician 
is successful), and a reasonable degree of skill both practitioner and 
student can, in the large proportion of all cases, attain their purpose. 

It is a popular error that the sole requisite for establishing a diag- 
nosis is the exhibition of an affected portion of the integument to the 
eye of him who is consulted with a view to its relief. The physician 
is supposed to inspect this surface attentively for a few moments, and 
then to pronounce definitely upon the nature of the disease present 
and the therapeutic measures to be adopted. While. such a procedure 
is possible to the expert in a limited number of cutaneous disorders, in 
a large number of cases far more than this is requisite, and, indeed, 
is fully as essential here as in the investigation of disease involving 
any other organ of the body. 

It is true that erythema, urticaria, dermatitis, eczema, purpura, 
alopecia, and many other affections of the skin may often be recog- 
nized after simple and brief inspection of the region involved ; but the 
cause of such disorders and their relation to the general health of the 
patient, all of which knowledge is essential to their proper treatment, 
can only be obtained after a much more thorough examination. As 
a rule, it is desirable, first, to secure a history of the physical and 
mental condition of the patient in the past; then should follow the 
special history of the disorders of the skin ; lastly, an examination of 
the patient and of the affected integument. The family history may 
be of value in making a diagnosis. For the purpose of methodically 
arriving at these facts, and of preserving them for future reference, 
they should systematically be recorded. The following are some of 
the points upon which it will generally be found useful to secure 
information : 

The name, residence, age, sex, occupation, and married or unmar- 
ried state of the patient should be known, as also, whenever prac- 
ticable, the health-history of parents and children. In the case of 

6 81 



82 GENEEAL DIAGNOSIS. 

women it is not only necessary to learn the history of the menstrual 
function in the past, but it is of the highest importance to be informed 
also as to the previous occurrence of abortions and miscarriages, and. 
if such have occurred, the order observed by these with relation to the 
birth of viable infants. The significance and value of several of these 
facts have been described in the chapter on Etiology. The history of 
the products of conception has a mosl importanl bearing upon the 
question of syphilitic infection. The absolute exclusion of syphilis in 
any obscure case is a long Btep in the direction of an accurate diag- 
nosis. Tn the instance of male patients, questions will usually elicit 
either admission or denial of the fact of a precedenl or preseul vene- 
real disease, and the answi rs Bhould be regarded as valueless or trust- 
worthy according a- they are or are not substantiated by corroBorative 
clinical facts. 

Then should follow some record of the habits of the patient, as to 

active or sedentary employment, bathing, E 1. and drink, including 

under the latter term the use of beer, vine, and spirits. The history 
of any previous disorders, whether of the skin or other organs, should 
be satisfactorily clear, and the dates of occurrence, recurrence, and 
convalescence be al least approximately discovered. The patienl 
should also make known whether he has had refreshing -1- ep : whether 
he has undergone mental anxieties (domestic, financial, etc 
whether he has suffered in his digestive, respiratory, circulatory, 
genito-urinary, or nervous system. Defects in elimination, assimila- 
tion, and nutrition should be noted; and when the Bympton 
disease of other organs than the -kin thi should be subjected 

to the proper physical examination. 

This much ascertained, the patienl Bhould 1"- encouraged to nar- 
rate as succinctly as possible, and as far as may be in his own terms, 
the history of the pn Bent cutaneous disorder. A systematic Beries of 
questions put by the examiner Bhould disclose, if possible: the cause 
of the disorder: its appearance when ;' nd any changes in 

character and type which have rred : the regions of the body 

affected, in order of involvement; the method of extension, by peri- 
pheral enlargement of the early area-, or by the appearance of new 
lesions at a distance from those first observed : the rapidity and regu- 
larity of the progress of the disease and its duration; the subjective 
sensations; and the influence of seasons and temperature upon the dis- 
order. The treatment to which the disease has been subiected should 
then be detailed, this frequently furnishing a key to the diagnosis 
and therapy of the malady. Tn a large proportion of all cases, ignor- 
ant! v directed and vicious internal or external medication has either 
begotten or aggravated the disease of the skin. This much ascer- 
tained, the physician is ready to examine the affected surface for 
himself. 

During, however, the verbal interrogations which are required for 
this part of the exploration of the case, the watchful and observant 
practitioner will probably have secured for himself some useful infor- 



DIAGNOSIS. 83 

mation of which the patient is totally unconscious. Much of this is 
difficult to describe, as it is the rich fruit of wide experience and care- 
ful scrutiny. With a gentle, courteous, and sympathizing manner the 
diagnostician must combine the art of a detective and the skill of a 
swordsman. Glancing occasionally at the face of his patient while 
making record of the answers given, he will, of course, have observed 
any eruption upon that portion of the body. He will have made a 
mental note of the temperament of the sufferer, and of any movement 
made by the latter indicating a tendency to scratch or rub portions 
of the skin. He will have noticed the posture, clothing, and head- 
apparel; the existence of hair on the scalp or extensive baldness; 
the condition of the exposed hands as indicating manual labor or the 
reverse; and, in the absence of facial lesions, will have observed the 
special tint of the skin of the face, as suggesting anaemia, chlorosis, or 
a general condition of cachexia. The facial expression, as indicative 
of anxiety or placidity, habits of debauch, sexual excesses, etc., will 
not have escaped his attention. All this and much more will possibly 
have enabled the questioner to direct his interrogatories into the 
channel in which they will elicit the most useful responses. The 
posture, cries, facial expression, and general condition of nutrition of 
the infant will have been no less carefully noted. 

Proceeding to the examination of the affected integument, the 
physician must assure himself of a good light, as colors are best dis- 
tinguished by daylight and artificial illumination should be reserved 
for exploration of the cavities of the body. The air of the apartment 
should be sufficiently warm to permit of exposure of the person with- 
out discomfort and without causing disturbance of the cutaneous cir- 
culation. Adult males and children of both sexes should have the 
clothing completely removed so that all portions of the skin may be 
inspected. One portion of the body may, however, be examined, and 
then covered if desired, while the examiner proceeds to direct his 
attention to another part. In the case of women the investigation 
should be conducted with the tact and delicacy to which the sex 
is entitled. 

The examination, whenever practicable, should extend over the 
entire surface of the integument. The importance of this point can 
scarcely be exaggerated. It must be remembered that the physician 
should be much wiser than his patient, and the assurances of the 
latter are always to be accepted with reserve. Thus, one who merely 
exposes his leg, stating that this is the only part of his body affected, 
may have concealed beneath his clothing extensive varicosities of the 
veins of the thigh, a typical syphilitic exanthem over the belly, a 
significant scar on the elbow, an extensive patch of tinea versicolor on 
the surface of the chest, or a blennorrhagic discharge from the urethra, 
the medication of which has induced the rash for which he seeks 
relief. These are not the rare, but are the common cases of a daily 
experience. 

Observation should be had at this time of the general and special 



84 GENERAL DIAGNOSIS. 

features of the eruption. As to the former, the following considera- 
i ions Bhould be borne in mind : 

The original manifestations of a cutaneous disease may be masked 
or entirely hidden by the lesions resulting from scratching, or by a 
dermatitis due to local applications, or to drugs swallowed for the 
relief of the original disorder. It is of the greatesl importance thai 
the accidental nature of these Bymptoms be recognized, as they other- 
wise lead to greal confusion in diagnosis. 

Rarely a disease involves the entire surface of the body, leaving 
no pari unaffected, and then is -aid to be universal in distribution; 
more frequently an eruption affects at one time several or most of 
the regions of the body-surface, and then is called generalized ; much 

more < imonly an eruption affects a considerable portion of bu1 

one or several regions, and i- Baid to be diffuse; or it is limited to 
small areas of one or several definite regions, and i- known as a loeal 

erupt ion. 

A symmetrical eruption, one equally distributed over correspond- 
ing regions of both Bides of the body, is rarely the resull of an etio- 
logical factor operating upon the outer -kin. It more often points to 
an efficienl cause of internal origin. An eruption affecting the cov- 
ered integument, never creeping oul upon the exposed Burfaces, 
suggests the operation of the clothing, a- the latter may chance to 
prove tlie nidus or protector of a parasite, the fabric which has been 
colored by a noxious dye. the recipient of a chemically altered secre- 
tion which has proved irritating to the Burface, the instrumenl of 
friction, or tin source "t" increased temperature at the surface by its 
non-conductivity of heat and unseasonable thickness. An eruption 
accompanied by excoriations and Bcratch-lines i- usually severest in 
the parts mosl accessible i<> t 1 1< - hand-, and leasl developed where the 

latter have the least play, a- over BOme parts of the hack. An erup- 
tion limited to the hand- i- likely t«. he one induced by an agent to 
which the hand- alone have been exposed. Such are the eruptions 
originating in the trades and domestic occupations; in the latter, an 
eruption more distinet on the right hand, and especially about the 
right thumb and index finger, tell- it- own Btory when the hand- 
worker i- not ambidextrous nor left-handed. Artificially and inten- 
tionally produced eruptions, a- in malingering, hysteria, menial de- 
pravity, and insanity, usually occur also in parts to which the right 
hand finds easy aco as. 

Eruptions occurring on the 1*a<-e. the hand-, and the genitalia of 
men. or on the face, hands, and mamma- of women, point to external 
contact or contagion (poison-ivy, scabies, croton-oil, etc. . since, next 
to the faee. the hands are more commonly brought in contact with the 
parts named in the s,. X e~ respectively, a- the wearing-apparel of each 
suc'Jiests. 

An eruption limited to the forehead suggests an inspection of the 
hat-band, the veil, or the overlying false hair: to the ears of women, 
a glimpse at possibly cheap ear-rings ; to the centre of the root of the 



DIAGNOSIS. 85 

neck, before or behind, a scrutiny of the collar-button and collar ; to 
the anus of the baby, an inquiry as to the changing of its napkins ; to 
the wrists of the adult, a question as to the cuffs worn; to the feet, 
information respecting gaiters, varicose veins, recently cut corns, and 
ill-fitting boots. Eruptions springing from each of these causes have 
been treated long and vainly as " diseases of the blood." 

Eruptions markedly asymmetrical are indicative of asymmetric- 
ally operating causes — that is, the accidents of environment, or else 
influences exerted within the body unequally on its two lateral halves. 
Thus, an orthopaedic apparatus worn to correct talipes excites a der- 
matitis of the leg of the affected side only ; and zoster of the trunk is 
evident on that side supplied by the intercostal nerve which has been 
inflamed. The greater stress may be laid on this peculiarity, as the 
law of symmetry, in eruptions not occasioned by causes operating on 
the outer skin, is faithfully observed in nature. The earlier syphi- 
lides, the quinine-exanthem, rubeola, and even lupus erythematosus, 
are remarkable illustrations of this fact. 

Proceeding with the visible characteristics of the disorder, the 
physician will not fail to note an acuteness or chronicity of the erup- 
tion ; also, the presence or absence of an exudate on the surface. 

After obtaining an impression of the general features of an erup- 
tion the individual lesions should be carefully studied. The type of 
lesion (papule, tubercle, vesicle, etc.) should be noted. When the 
lesions are multiform the different types should be examined to de- 
termine, if possible, which are primary and which consecutive in 
appearance, which are essential and which accidental in the process. 
For the purpose of studying the characteristics of the individual 
lesions, those of most recent appearance (usually at the border of a 
patch), and as yet unmodified by scratching, treatment, and other 
influences, should be selected. Often, however, the full evolution of 
a lesion requires time, and its successive stages should be determined 
by observing a number of lesions of different ages. 

The arrangement of lesions varies greatly in different diseases. 
When grouped such lesions may develop in circular, oval, angular, or 
irregular-shaped areas; or in circinate, gyrate, serpiginous, straight, 
or irregular bands and lines. In some affections (as ringworm, 
psoriasis, syphilis) the areas may become clear in the centre as the 
border progresses. Lesions may be grouped, and yet discrete in that 
each lesion preserves its outline and identity ; or they may coalesce so 
completely that all trace of the form of the individual lesion is lost. 
The definition of lesions is another important diagnostic feature 
in which cutaneous affections vary greatly : the line dividing the dis- 
eased from the normal skin may be so sharp and fine that it can be 
traced with the point of a pin ; or the lesion may shade so gradually 
into the normal skin that its outline cannot be definitely determined, 
and it is said to have poor definition or none. 

The color of lesions of the skin often depends greatly upon circum- 
stances having no bearing upon the disease in question. It thus varies 



86 GENERAL DIAGNOSIS. 

with the natural color (light or dark) of the individual's skin, with 
the temperature of the surface, and with the amount of irritation to 
which the surface has been subjected by friction with rough clothing, 
scratching, treatment, etc. There are. however, some diseases (syph- 
ilis, lichen planus, tinea versicolor, favus, and others; in which the 
color may be of great importance in the diagnosis, and there are many 
maladies in which consideration of this characteristic of the eruption 
is of value if the accidental modifications be borne in mind. The 
acuteness or chronicity of a disease is often indicated by the color of 
the lesions. The persistence, modification, or disappearance of color 
under pressure should be noted. For this purpose a small glass disc 
or glass tongue-depressor is better than the tinger. 

In judging of the size of a lesion it is sometimes important to 
learn, by palpation, how much of it is above the general surface of the 
skin and how much is more deeply situated. In noting the Bhape of 
papules, tubercle-, vesicles, and pustules, both apex and base should 
be taken into consideration. Thus, the apex may 1"- pointed (acumi- 
nate), rounded (obtuse), flal (plane), or depressed (umbilicated). 
The base may be round, oval, angular, polygonal, <»r Irregular. 

The situation of lesions in <>r about the hair-follicles or at the 
opening of the ducts of the Bebaceous <»r coil-glands is a diag 
point of great value. It i- Important to know if certain lesions ap- 
peared first upon normal skin, or if they originated in other lesions. 
Thus, vesicles and pustules may arise from Bound surfaces, or from 
the apices of papules or tubercles. The majority of even the ele- 
mentary Lesions are probably preceded by macules, which, ho 
are often bo transitory as to be unrecognized and unimportant 

The career of an individual lesion, which often bears do relation 
to the duration of the disease as a whole, Bhould be noted. Thus, tin- 
vesicle of eczema rarely exists a- such for more than a few hours, 
though by the formation of new vesicles eczema may persi 
months, while in zoster, individual vesicles last .-everal days, though 
the disease as a whole i- short-lived. In some diseases the type of 
lesion remains the Bame throughout it- career unless modified by treat- 
ment or external influences, while in others the type changi - or i^ 
complicated by other types. Thus, the papule may be modified by 
developing at it- apex a vesicle or pustule. The career of lesions can 
usually be studied, not only by watching them from day to day, but 
also — and more easily — by observing at one time a number of lesions 
in various stages of development. 

A- the lesions of different affections vary greatly in their evolu- 
tion and career, so do they in their evolution. While in the majority 
of instances it is the recent and newly formed lesion that i- 
useful for purposes of study, there is often much to be learned from 
the manner in which lesions disappear and in the traces they leave. 
The papule or tubercle which ulcerates usually suggests (aside 
from some rare disease) syphilis, tuberculosis, or carcinoma, and 
may be sufficient to exclude from the diagnosis the possibility of 



DIAGNOSIS. 87 

psoriasis, seborrhoea, and other superficial affections. In a doubtful 
case the termination of some of the lesions in scar-tissue may be the 
one fact needed to make a differential diagnosis between seborrhoea 
and lupus erythematosus, or between a circinate form of psoriasis 
and a similar type of syphilitic eruption. Pigmentation sufficiently 
characteristic for a diagnosis is left after the otherwise complete invo- 
lution of some lesions. This is most frequently true in zoster, lichen 
planus, and some forms of syphilitic eruptions. In estimating the 
time of involution of lesions and in making a prognosis regarding the 
disappearance of pigmentation (a point upon which patients are often 
solicitous) it should be remembered that pigment is usually re- 
moved very slowly from the lower extremities and other dependent 
portions of the body, and that in such localities it may persist for 
months or years after it has disappeared from parts in which the 
return-circulation is better. 

Certain lesions have special features that should be studied. These 
are given in detail in the last division of the outline at the close of 
this chapter. 

Before concluding his examination the physician will rupture a 
bleb, pustule, or vesicle, should such be found, to discover the nature 
of its contents. He will remove one or several crusts in sight, to 
expose the surface on which they rest. He will scrape away a few 
scales with the dermal curette for a similar reason. He will pinch 
between thumb and finger a portion of each part, in order to deter- 
mine its infiltrated condition, its atrophy, or its attachment to the 
tissues beneath. He will pass his hands over the surface to recognize 
the firmness or the softness of the lesions, their inflammatory, hyper- 
plastic, or neoplastic character, their dryness or moisture, and the 
existence of sebaceous or of perspiratory secretion. He will look at 
the mouths of the follicles where such secretion is retained or is abun- 
dantly exuded. He will discover any lice or their ova between or 
upon the hairs, any ascarides at play about the anus, any morbid for- 
mation of the nail or deformity of its matrix. He will examine for 
inguinal, post-cervical, axillary, and epitrochlear adenopathy, and 
will thus be often greatly aided in his task. This done, he will ques- 
tion in turn for himself, and by the methods recognized in medical 
science, the organs of the body other than the skin. He will inspect 
the tongue carefully, and if then he considers himself through with 
the mouth he will be guilty of great error. The gums rarely deceive 
the questioning eye ; the inside of the lips, the fauces, and the tonsils 
are all to be searched. A mucous patch here will often echo the story 
of a palmar or a plantar syphiloderm. The laryngoscope may be called 
for in syphilis, cancer, lupus, and leprosy. The degree of distention 
of the belly and the region of hepatic dulness should not be overlooked. 
The genitalia of men, and of children and infants, can usually be 
explored. For women unaffected with syphilis or disease limited to 
these parts an exception in this particular should usually be made. 

In many cases the microscopical and bacteriological examination 



88 GENEZAL DIAGNOSIS. 

of hairs, scales, crusts, exudate, or tissue is essential to the diagnosis. 
With the necessary reserve of all very obscure cases, it may be said 
that the physician who has conscientiously conducted an examination 
after the manner described above, is in possession of the diagnosis for 
which he seeks. If the facts thus acquired have properly been re- 
corded, and yet do not spell out such a diagnosis to his eyes, they will 
probably be legible to others with a wider experience or riper judg- 
ment, to whom such a record may be shown. It is not claimed that 
this exhaustive method of examination is requisite in every case, as, 
for example, in order to recognize favus or to differentiate erysipelas 
from erythema. But it is certain thai few obscure cases of skin dis- 
ease will remain such under severe scrutiny, and the establishment of 
a thorough and exhaustive method of examination is important in the 
curliest experience with disease. Le1 the studenl or the practitioner 
conduct Buch an examination in the firsl ifw cases of eruption upon 
the surface of the body for which his advice is sought, and he will 
establish a habil of observation in comparison with which hi- pe- 
cuniary or professional success in the management of the same cases 

will indeed he of trivial worth. 

Upon one special point should the inexperienced physician be 
guarded. It relates to the acceptance of a diagnosis which La not 
based upon such an examination as that given in outline above. A 
diagnosis by a patient is usually faulty, and the vrerdicl of even skilled 
practitioners may be founded upon an error. The careful diagnos- 
tician should begin his task in a spirit of skepticism, and pronounce 
definitely only upon ascertained facts. The man who says he has an 
"eczema" may be louse-bitten; the woman who has been "over- 
heated" may prove Byphilitic. The patient recognized as suffering 
from ringworm of the beard may nol have been infected under the 
hands of a barber. Finally, the eruptions upon patients unmistakably 
syphilitic are often of other than Byphilitic origin. The-.- infected 
subjects men. women, and children— are exposed daily to the acci- 
dents from which the non-infected sutler. They exhibit acne, physio- 
logical alopecia, and dermatitis medicamentosa equally with the non- 
syphilitic. 

Tuberculin.— -Three methods of administering tuberculin for pur- 
poses of diagnosis are now available: First, by giving hypodermat- 
ically Koch*- old tuberculin, second, the "Von Pirquet" tuberculin 
test ; and third, the ophthalmo^tuberculin test 

Hypodermic Test. — Koch's old tuberculin is given preferably at 
midnight beginning with one quarter of a milligram (.00025). The 
patient should have been prepared by being kept quid for two days 
preceding the test and his temperature taken every two hours to 
determine the normal. If this be found to amount to 100 or 
more degrees the test should not be used. The reaction begins 
in from eight to twenty hours after the injection, usually in eighteen 
hours, and is indicated by a rise in temperature to 100, 101, or even 



DIAGNOSIS. 89 

104 or 105 degrees. This is accompanied by severe headache, a feel- 
ing of general malaise, pain in the back and limbs, loss of appetite, at 
times nausea and vomiting, and if severe, by grave prostration. As a 
rule the symptoms subside in twenty-four hours, but may require two 
or three days to disappear. In addition to the general symptoms 
above recorded a local reaction is evident in the cutaneous lesion ex- 
hibited by redness and other inflammatory phenomena. If no reac- 
tion occurs a second dose of one milligram (.001) is given in three 
days. If still no reaction, a third dose of three milligrams (.003) is 
given in another three days. If after this no reaction is evident 
the diagnosis may be considered negative as to tuberculosis. 

" Von Pirquet " Test.— This is practically a local vaccination 
method. Two solutions are necessary: First a 25 per cent, solution 
of Koch's old tuberculin; second, a blank solution. Dr. Lincoln 1 
suggests for the first solution one part tuberculin, one part five per 
cent, carbolic acid in glycerin, and two parts sterile 0.85 per cent, 
salt solution. The blank solution represents one part five per cent, 
carbolic acid in glycerine and three parts sterile 0.85 per cent, salt 
solution. 

The arm is cleansed as in ordinary vaccination and one drop of 
each of the above solutions is placed on the cleansed area about two 
inches apart. Each is then scarified into the skin, with care not 
to make the surface bleed. Each drop is allowed to dry and is pro- 
tected by a shield. In twenty to twenty-four hours the reaction, if 
it occur, is at its maximum and is exhibited as a hyperEemic, sharply 
circumscribed, infiltrated lesion. There may be vesicle-formation 
followed by crusting. In the area treated by the blank solution no 
significant change should occur. The reaction subsides in one to 
three weeks and is unacompanied by constitutional symptoms. 

Ophthalmo-tuberculin Test. — A one per cent, solution of tuberculin 
is used. This may be prepared by adding one tablet of prepared 
tuberculin (to be had in the market, prepared for this purpose) to 
one c.c. of sterile 0.85 per cent, salt solution. 

The eyes should be free from all evidence of inflammatory changes 
when the test is made. If found normal, one drop of the solution 
named is instilled into one eye. The liquid should be moderately 
warm and then diffused over the conjunctiva by gentle manipula- 
tion of the lower lid. The reaction reaches its maximum in twenty- 
four to thirty-six hours and subsides in two days to one week as a rule, 
and is exhibited as a catarrhal conjunctivitis. Usually no subjec- 
tive sensations are present, though mild burning and smarting with 
photophobia may occur. 

A positive reaction is indicative of tuberculosis in some region of 
the body provided the eye has not been previously tested. It is im- 
portant to note that tests repeated after five to eight days are valueless. 

The following outline for the methodical examination of a patient 

1 Lincoln, May C. ; Journ. Amer. Med. Assoc, 1908 ; vol. li., 21, 1756-1761. 



90 



GENERAL DIAGNOSIS. 



affected with skin disease is based on the subjects considered in the 
preceding pages, and is given in such detail that a careful investiga- 
tion of the questions suggested should furnish material for all but 
exceptional cases. For the average case much may be omitted. 

The first attempts to follow such a scheme are necessarily tedious, 
and therefore often discouraging; but one patienl thus carefully ex- 
;i mined is of greater educational value than an aimless and indefinite 
examination of a dozen cases. There is no greater economy of time 
than is found in methodical and systematic habits of work. 



I. Name and RESIDENCE. 
II. Age. 

III. Sex. 

IV. Married or Unmarried. 

1. Children. 

a. Living. 
u. Dead. 

2. Abortions or sflscarriages. 
V. Famim SlSTOftl . 

VI. Individual History, including 
that of previout skin diseases. 
VII. Occupa 

VIII. Habits, of eating, drinking, bath- 
ing, tobacco usagi . < /<•. 
i.\. Present State <>k Hi.ai.th. 

I \ oti tin , ondiHon of tin digit 

!H inli, in nun a. a,,, t , 



systems; also, detects in us 

elmilation, < li initiation, ami nu 

li, I, nil I 

X. History of Pri - r His 

EAS' 

i Caus< if known. 
2. Character al I 
.':. Sites affected in order. 
4. Manner of progressing. 

n. Slow or rapid. 

'i. Steadj or Irregular. 
with exacerbal Ions and 
remli 
</. With periods of • 

lom from symptoms, 
ages in chai 
«;. Subjective sensations. 
7. Dui 

temperature and sen- 

:• Treatment to date. 



OBJ I ■< I ivi SI M P 



A. AOCD) ,/,/, I,, 

scratchmn. Inatiiu nt . < '<■. 
B - 

i. Tin'.. 
2. < ■ • 

3 Diffuse. 

■i. Local. . inth 

iinj. occupation, 1 1 

I. Uniformity, or multiformity. 
U. Arrangement 

1. Isolated. 

2. Grouped (Cirdnate, linear. 

4. Coalescing. 

5. Irregular 

III. Definition. {Sharp, fair, poor, or 

none.) 
I V. Elevation, or depression. 
V. Color. 

1. Persistent. 

2. Changing or disappearing un- 

der pressure. 
VI. Shape. 

1. Apex. 

2. Base. 
VII. Size. 

1. Superficial. 

2. Deep. 

VI II. Anatomical site. 



" try. 

-. ,,r rln,,' 

E. sf< 

l. Elementary [macule, papule, 
in',, i , I, . tumor, 

pustuil . or hit h i . 

■ ' 

I A. I onsiatenee. 

1. Firm. 

X. 1. 

1 color. 

2. Infiltration. 
XI. Evolution. 

1 From sound skin. 

2 Prom other let 
All. Career. 

l. Transitory. 
•J. Persistent. 
1 ype. 
n. Simple. 
'/. ("'hanging. 
<■. Modified. 
XT 1 1. Involution. 

1. Resorption. 

2. Exfoliation. 

3. Ulceration. 

4. Atrophy, etc. 
XIV. Sequelae. 

1. Stains. 

2. Scars. 



DIAGNOSIS. 



SPECIAL FEATURES TO BE OBSERVED IN CERTAIN LESIONS. 



A. Vesicles, Pustules, or Blebs. 
I. Eoof. 

1. Tense. 

2. Flaccid. 

3. Easily ruptured. 
II. Contents. 

1. Translucent, or opaque. 

2. Serous. 

3. Purulent. 

4. Hemorrhagic. 

III. Surface beneath. 

IV. Areola. 

V. Involution. 

1. Desiccation. 

2. Rupture. 

3. Crusts. 

B. Scales. 
I. Size. 

II. Color. 

III. Quantity. 

IV. Consistence. 

1. Dry. 

2. Fatty. 

3. Friable. 

4. Tough. 
V. Attachment. 

1. Firm. 

2. Slight. 

VI. Surface beneath. 

1. Color. 

2. Dry. 

3. Greasy. 

4. Hemorrhagic. 

C. Ckusts. 

I. Size. 
II. Shape. 

III. Color. 

IV. Composition. 

1. Serum. 

2. Pus. 

3. Blood. 
V. Attachment. 

VI. Thickness. 
VII. Consistence. 
VIII. Surface beneath. 

D. Excoriations. 
I. Distribution. 

II. Shape. 

III. Arrangement. 

IV. Belation to other lesions. 
V. Exudation. 

E. Fissures. 

I. Distribution. 
II. Size. 

1. Length. 

2. Depth. 
III. Pain. 



IV. Moisture. 

F. Ulcers. 

I. Size. 
II. Depth. 

III. Contour. 
IV. Base. 

1. Soft. 

2. Infiltrated. 

3. Indurated. 
V. Edges. 

1. Sloping. 

2. Perpendicular. 

3. Punched. 

4. Ragged. 

5. Everted. 

6. Undermined. 

7. Soft. 

8. Indurated. 
VI. Floor. 

1. Smooth. 

2. Uneven. 

3. Clean. 

4. Pus-covered. 

5. Granular. 

6. Sloughing. 

7. Hemorrhagic. 

8. Glazed. 
VII. Secretion. 

1. Scanty. 

2. Profuse. 

3. Serous. 

4. Purulent. 

5. Hemorrhagic. 

6. Odor. 
VIII. Pain. 

IX. Crust. 

X. Evolution. 

XL Duration. 

XII. Involution. 

(Note carefully the number and 
location of ulcers, the age of 
the patient, and the character 
of scars if present.) 

G. Scars. 

I. Size. 

II. Shape. 

III. Color. 

IV. Depression, or elevation. 
V. Texture. 

1. Soft, pliable. 

2. Hard, indurated. 

3. Thin. 

4. Thick. 

5. Smooth. 

6. Rough, corded. 
VI. Attachment. 

VII. Deformity. 
VIII. Subjective sensation. 

IX. Absence or presence of hairs, 
glands, and papillae. 



Yf. GENERAL PROGNOSIS. 



The prognosis of mosl diseases of the human body is formulated 
with a view to the decision of the serious question of life or death. 
Occasionally this question arises in connection wiili skin diseases. 
Many of the latter are trivial, Borne are grave, a few are inevitably 
fatal in their termination. Thus general exfoliative dermatitis, lep- 
rosy, sarcoma, carcinoma, m times lichen ruber, and variola in the 
unprotected are of grave portent ; while the ordinary congestions and 
exudations, the greal majority of all cases of acquired syphilis in 
adults, and the entirely curable diseases induced by parasites do not 
excite alarm in the breasl of the average patienl with respect to his 
longer ity. 

The questions, however, as to his future, which are urgently 
pressed by the victim of cutaneous disease, are 1 >* »t 1 1 numerous and 
important. Be is anxious as to the time during which he must Buffer ; 
as i" the possibility of conveying the disease to lii- progeny or other 
members of his family; as to the disfigurement of his person that 
may result ; as to the Bears which he may carry for the remainder of 
his life; as to the possible recurrences of his malady in the future. 
The responses to these questions will largely be influenced by the 
prognosis of the ph\ sician. 

Seme diseases of the Bkin are acute, pursue a rapid course, and 
are prompl to disappear. < toners are chronic, rebellious i" treatment 
of the most energetic and Bkilful character. Others, again, though 
not shortening life, are never relieved while life is continued. Seme 
disappear only to reappear at more or less regular intervals. 1 here 
are cutaneous diseases which affect one individual bul once in his 
lifetime: others which reappear at the instant ihe patient i- again ex- 
posed to their exciting cause. There are cutaneous diseases so dis- 
torting and destructive in their effects that their victims have com- 
mitted suicide under the influence of the morbid emotions which have 
been as a consequence experienced. 

The mental distress occasioned by even an insignificant cutaneous 
disorder is often out of all proportion to its exciting cause, and this 
should always be regarded in establishing a prognosis. The sexual 
hypochondriac has been made insane by an acne: and the man or 
woman affected with syphilis has been made wretched for years by a 
recurrent erythema. 

Again, a disease of the skin may coexist with grave lesions of in- 
ternal organs, and the prognosis of the disease of the one be greatly 
influenced by that demanded by the ether; thus, there U occasional 
coexistence of syphilis and phthisis. Pruritus may be associated 

92 



PEOGNOSIS. 93 

with albuminuria ; and the eczema of an infant starving for want of 
breast-milk may hasten its marasmus to a fatal termination. 

Upon the answers given to his patient inquiring as to the prog- 
nosis of the disease of the latter, will largely depend the professional 
success of the physician. Scrupulous honesty should here be welded 
with all the skill that science can command. That a disease does not 
endanger life is not an argument in favor of its amenability to treat- 
ment. The practitioner should never suffer himself to be pushed by 
his patient to the position that an obstinate disease is readily manage- 
able. It is the height of folly to estimate lightly that zoster of the 
forehead, the scars of which the patient may exhibit to all who after- 
ward look upon his face both in life and in death. He who engages to 
relieve an alopecia areata in the month may have a year in which to 
repent his precipitancy. There is no way in which the conscientious 
physician can so readily secure the confidence of his patient, and 
with it that willingness to submit to appropriate treatment which is 
begotten of such confidence, as by demonstrating his ability to fore- 
cast the future of a disease; in other words, to describe accurately 
its prognosis. 



VII. GENERAL THERAPElTK'S 



A consideration of the subject of the met hods of treating skin 
diseases in general suggests ;it once the intimate relation which -nl>- 
sists between the integumenl and other organs of the body. The 
etiology of one largely explains the causes of disease in nil. The 
pathological processes in eaeh are subordinated to the same general 
laws. The principles of treatment are very similar in all the disor- 
ders of the body. 

The object t<> In- attained by treating a cutaneous disease is, first, 
its complete relief; secondly, where relief is impossible, such manage- 
ment of the morbid process :i- will mitigate its severity and render 
the victim of the disease more comfortable. A higher and more 
scientific achievement than either is the prophylaxis by which man 
is enabled to escape the disease altogether. lie can by his wisdom 
largely diminish ili<' danger to which his integumenl is expose.] ; he 
can, to a certain extent, shelter himself from extremes of temperature, 
traumatism, toxic agents, and contagious diseases; he can, by observ- 
ing the simple rules of hygiene, fortify his Bkin against 'he lesser 
evils which may befall it. Here, however, the subject under con- 
sideration involves disease which i- actually presenl and in progress. 

The management of diseases of the skin demands <»f the practi- 
tioner a sound knowledge of general medicine and mi experience in 
disorders other than those of the integument. Dermatology is a 
branch of general medicine, and hi' who would succeed in 'he one 
department must at lea-t he at home in 'he other. lie who cannot 
succeed in the one field will almost surely fail to secure 'he best re- 
sults in the other. Much indeed of the management of diseases of the 
skin can be correctly described as the pure practice of medicine. 
Many of the methods, most of the means of diagnosis, much of the 
pharmaceutieal aid utilized by the general practitioner, are indis- 
pensable in the field of dermatology. 

It is scarcely needful to set it down at this date that the old 
doctrines respecting both the danger of " driving in " certain diseases 
of the skin, and of the importance of " driving out " others, are relies 
of a superstitious ignorance. There is no disease of the skin the 
continuance of which offers a bar to other disorders or furnishes a 
guarantee of the future health of the patient. There is no disease 
of the skin which does not call for relief as promptly as the require- 
ments and safeguards of science will permit. The retrocession of the 
exanthematous symptoms of a systemic poison are not of the class 
of involution of lesions to which attention is here directed. 

In beginning the treatment of disorders of the skin it is scarcely 

94 



TEEBAPEUTICS. 95 

necessary to repeat that the diagnosis should be established by the 
methods already detailed ; and that in attempting to adjust remedies 
to the morbid state due attention must be given to the past history of 
the complaint, to its remote or immediate causes, to its duration, to 
the nature of the disease (whether the latter has changed in type or 
severity since the beginning), and in particular to the special features 
presented 'at the moment of instituting treatment. The matter of 
diet is one with respect to which experts are not as yet upon all 
points agreed. In general it may be said that in all inflammatory 
affections the diet should include food which is simple, digestible, and 
free from excess of nitrogenous and hydrocarbonaceous principles. 
The diet appropriate for the gouty state in the majority of gouty pa- 
tients suffering from dermatoses must be rigidly enforced, even ad- 
mitting that too severe a regimen is to be deprecated for the gouty 
when not actually suffering from a crisis of the disease. In all 
attacks of urticaria the food permitted should be made to correspond 
carefully with the list of articles known to be incapable of aggravat- 
ing the disorder, and too much importance cannot be attributed to 
the regulation of the food of infants and children affected especially 
with eczema. Tn glycosuric xanthoma, in the pruritus of albumin- 
uria, in the tuberculoses of the skin, in acne cachecticorum, and in 
other disorders the selection of a dietary appropriate to the systemic 
state is of vital importance. On the other hand, it is to be conceded 
that in some cutaneous maladies, such as vitiligo, the disorders due 
to vegetable and animal parasites, in m oil u scum, and in other affec- 
tions which might be named, the subject of dietetics is without im- 
portance. 

Like all other diseases of the body, those of the skin may be 
divided into three classes with relatively fixed limits. 

The first class embraces all the diseases which have a natural ten- 
dency to pursue their course to a favorable termination. It includes 
all those affections which, either mild or severe, require absolutely 
no treatment of an active character. It is the duty of the skilful 
physician to watch the evolution of these maladies, and to discharge 
a most important part by refraining from therapeutic measures 
which in such cases might prove hurtful. By his judicious coun- 
sel, also, he hinders patients and their friends from pursuing a 
course which might prove prejudicial to the disease. 

The second class embraces all those skin affections which are 
either inevitably fatal or hopelessly remediless while life is prolonged. 
Fortunately, this includes but a small proportion of the large list. 
Here the duty of the physician is plain. He should assuage pain, 
attempt to relieve deformity, administer to the comfort of the afflicted 
in other ways, and by his patient courage inspire confidence and 
hope. It must not be forgotten that the skill of man has not yet 
reached the acme of human need. In the presence of many diseases 
of the body he stands absolutely helpless, and the speediest way to 
success in such cases is to begin by an honest admission of the plain 
fact. 



96 GENERAL THERAPEUTICS. 

The third class of affections naturally embraces all not included 
in the first two named. Here disease may be prolonged or be 
shortened in its course, rendered acute or chronic, made more or less 
endurable, permitted to become inveterate, or absolutely be relieved 
by prompt and energetic measures, according as it is, or is not, judic- 
iously and skilfully managed. Here arc gained the most brilliant 
successes of the dermatologist ; here also occur his mosl humiliating 
failures. 

In the presence of a cutaneous disease which requires treatment 
the question naturally arises as 1" whether this treatment shall be 
internal-thai is, by medicaments ingested; or external — thai is, by 
local therapeusis; or by combination of the two methods at the same 
time. 

INTERNAL TREATMENT. 

With regard to the question of internal treatment, which is one 
of pressing importance, il can Bafeh be Baid thai there are ao reme- 
dies to be given by the mouth thai can be described as certainly and 
specifically curative of the diseases of the skin. The number of 
medicinal agents employed with this end in view is incredibly large, 
by far the greater pari being obtained from the vegetable kingdom. 
\\\\\i few exceptions, some of which are enumerated below, the moal 
esteemed of these agents exerl only an indirect therapeutic effect 
upon the integument The larger number of medicaments thus 
used are, it must be admitted, without value of any kind, but will 
probably continue to be vaunted as possessing specific virtue so long 
as credulity on the one hand, and avarice on the other, move the 
mass of mankind. 

Arsenic has long stood at the head of the lisl of remedies as valu- 
able, when ingested, for the relief of cutaneous disorders. Et i- 
known to exerl its effects almosl exclusively upon the epithelia of the 
skin, and upon these, bo far as therapeutic effects are eon. •.•me. 1. only 
when they are the seal of subacute and chronic exudation. Upon 
the acutely inflamed epidermis the action of arsenic is unfavorable. 
If given for long periods of time, it may produce a generalized pig- 
mentation and. occasionally, a generalized hyperkeratosis of the skin. 
It frequently produces excessive keratosis of the palms and sole-, 
which in special cases has terminated in cancer of the skin. Operat- 
ing favorably in this limited class of cases, it also operates -lowly, 
requiring months for the production of it- curative effects. Its ad- 
ministration is attended at all times with the hazard of producing 
toxic effects, which, however, when the result of the exhibition of 
the drug in medicinal doses, are limited usually to a mild exanthem 
upon the skin, moderate coryza, and some redness from congestion of 
the vessels in the eyes and eyelids. 

Arsenic is used chiefly in psoriasis, acne, squamous eczema, 
pemphigus, and lichen ruber, its doses in case of children being rela- 
tively large. It should be administered only after eating, and a 



INTERNAL TREATMENT. 97 

minimum dose first be employed in order to test the susceptibility 
of the patient to its action. It should be remembered that the toxic 
effect of this, as also of several of the other drugs mentioned below, 
is often speedily noticed after the first exhibition of a relatively small 
dose. Toleration once established, the dosage may be cautiously 
increased. 

The forms in which arsenic is usually administered are: the 
preparations of arsenous acid, such as the popular tablet-triturates 
made up in different and most commonly administered doses; the 
liquor potasii arsenitis (Fowler's solution) ; the liquor arsenici et 
hydrargyri iodidi (Donovan's solution) ; the liquor arsenici chloridi 
(de Valangin's solution) ; and the Asiatic pill. Duhring's modifi- 
cation of this pill is obtained by making 2 grains (0.13) of arsenous 
acid, and 32 grains (2.13) each of black pepper and licorice powder 
into thirty-two pills by the aid of a sufficient quantity of gum 
Arabic and water. Arsenic is also at times advantageously combined 
with other indicated medicinal substances, such as iron and potassium 
iodide. 

An unprejudiced view of the value of arsenic, even in cases 
properly selected for its internal administration, justifies the con- 
clusion that it is in diseases of the skin a remedy of uncertain effect, 
and in that proportion disappointing. After collation of the experi- 
ence of experts it has been shown that the common practice of giving 
arsenic in many cutaneous diseases in both harmful and irrational, 
not merely because of its effect in inducing cutaneous congestion and 
pruritus, but also because of the reliance placed upon it to the ex- 
clusion of other and better methods of treatment ; and that the bene- 
ficial effects supposed to follow its administration are often due to 
other causes. ISTo series of carefully recorded cases has ever been 
published in which notable therapeutical results have been shown to 
result solely from its administration. Even in pemphigus, psoriasis, 
chronic eczema, and lichen ruber, in which arsenic has been thought 
to possess special efficacy, it has in cases conspicuously failed. 

It is safest to conclude, first, that arsenic, instead of being one 
of the earliest, should be one of the last remedies to be selected in 
the management of cutaneous diseases by the general practitioner; 
secondly, that, when thus selected, its value will probably prove great- 
est if the eruptive lesions be seated superficially, be generalized, 
diffused, or in evident association with neurotic symptoms ; thirdly, 
that in any case its failure to relieve should not be regarded as 
definite, if only Fowler's solution has been administered. 

Sodium Cacodylate. — This drug is an organic compound of arse- 
nic and may be used, where arsenic is indicated. It is claimed for 
the drug that large doses may be used without irritating effects 
whether exhibited hypodermatically or per os. It has been found 
of value in the treatment of psoriasis, lichen planus, dermatitis 
herpetiformis, etc. The dosage should be smaller than commonly 
recommended even though it has the reputation of being nontoxic, 

7 



98 GENERAL THERAPEUTICS. 

A safe quantity to begin with ranges from grs. 1/30 (.002) to grs. 
1/15 (.004) given three times daily after food. 

Atoxyl (Meia-arsenious-anilide) . — This drug has given brilliant 
results in syphilis, psoriasis, dermatitis herpetiformis, lichen planus, 
pemphigus, etc. It has been exhibited in dosage much greater than 
other preparations can be given. Neisser has demonstrated its value 
in syphilis in apes. While it appears to be a preparation of groat 
merit, it is not without danger as untoward results recorded demon- 
strate. It is given hypodermatically in doses up to three grains (.2) 
once in three days. Groat caution is recommended in its use. 

Mercury is a remedy of great value in cutaneous as in other affec- 
tions. Its specific action upon the liver and intestinal secretions calls 
for its employment in many cases in which intestinal elimination is 
deficient, in which there is habitual constipation, and in which there 
is a decided tendency to congestion of the blood-vessels of the head, 
of the anogenital region, and even of the lower extremities. In 
all of the distinctly gouty dermatoses, in all eczemas of the florid- 
faced type of patients, in manv case- of intense pruritus resulting 
from toxic influences, and in almost all the eczemas of in fancy and 
childhood, calomel, blue pill, and the gray powder are well nigh in- 
dispensable in securing the speediesl and happiesl results. Indeed, 
there are few adult patients seeking relief from a simple inflamma- 
tory affection of tbe skin and having at the same time a coated tongue, 
an offensive breath, and a loaded colon, who will not be benefited 
at the outset of treatment by free catharsis under tbe influence of a 
mercurial. In many cases indeed of aggravated types of endorse- 
ment of the skin, localized or generalized, a dose of bine mass may 
be given at night, on successive nights, or for a fortnight or more, 
and followed by a saline laxative in tbe morning, with tbe best effect 
upon the exanthem present. 

Mercury in the treatment of Byphilodermata is <>f incontestable 
value, and its injudicious employment in manv e;i^e~ springe from 
that precise fact. Tbe vulgar prejudice that manv disorders of the 
skin, really not syphilitic, are obscure manifestations of lues in a pre- 
ceding generation and amenable to mercurial treatment, is a striking 
illustration of the necessity 'of accurate diagnosis in cutaneous dis- 
eases. When syphilodermata are present corrosive sublimate is often 
superseded, in consequence of its irritative effects, by the compounds 
of the metal with iodine. The gray powder is useful chiefly in 
case of infants and children, though its occasional development 
of the corrosive chloride has limited its employment. Calomel and 
the mercurial pill should be employed only for transient effect, as 
when administered for long periods they are much more than the 
other preparations mentioned likely to produce ptyalism. 

Iodine.. — This drug and its compounds are also chiefly used in 
syphilitic disorders of the skin, but they possess a wider range of 
value than the mercurials in the treatment of other cutaneous af- 
fections. Here, too, the abuse of the drug furnishes a long list of cu- 



INTERNAL TREATMENT. 99 

taneous disorders either originated or aggravated by its employment. 
As in the use of arsenic, toleration should be established before large 
doses are exhibited. The compounds chiefly used are the iodides 
of potassium, sodium, lithium, and ammonium; iodo-nucleoid, iodi- 
pin, and iodoform. Iodine has been administered for the relief of 
the scrofulodermata, lupus, keloid, psoriasis, and syphilitic affections 
of the skin. As to the latter, it may be added that in the earlier 
symptoms of lues it is often a source of positive injury. 

Cod-liver Oil. — This oil is a remedy of special value in diseases 
of the skin, and was for that reason held in high favor by the dis- 
tinguished Hebra, though its action is almost exclusively that of a nu- 
trient of the general system. It is employed chiefly for its roborant 
effects, which are similar to those of the digestible aliments. Its 
special value in the treatment of infants and children affected with 
cutaneous diseases cannot be questioned. It is moreover, of great 
use in maturer years and is advantageously exhibited in eczema, 
lupus and other tuberculous affections, syphilis, scleroderma, and in 
all disorders of the integument accompanied by wasting. 

Cathartics, Alkalies, and Diuretics. — These have an important 
place in the list of remedies valuable in the management of skin 
affections. Cathartics are chiefly valuable in eliminating effete or 
toxic products, but they are effective also in reducing congestion of 
the body-surface. The value of mercurials in this connection has been 
already suggested. The saline laxatives and cathartics also are of 
great service, especially the magnesic and sodic sulphates, and the 
Eochelle, Carlsprudel, and Hunyadi Janos salts. The useful and 
frequently ordered mistura ferri acida is compounded as follows: 



Magnes. sulphat., 


3i ss ; 


45 




Acid, sulph. arom. (vel dilut.), 


3j; 


4 




Ferri sulphat., 


gr. viij 




50 


Aq. menth. piper., 


ad ^iv; 


120 


M. (filtra). 



Sig. A tablespoonful in hot or cold water before breakfast daily. 

The alkalies are extremely useful in all cases of gouty disorder, 
and in erythema, acne, and certain forms of eczema. The carbon- 
ates of sodium, potassium, and lithium are chiefly employed, as well 
as the liquor potassse. The prevalent misconception of the value of 
lithium carbonate and other salts of the same base has produced a re- 
action which suggests a preference of one of the other alkalies when 
such are indicated. Diuretics, with the exception of water, are less 
valuable in cutaneous than in other affections, but they yet are ad- 
ministered often with special advantage in inflammatory disorders. 

. Water. — Water when drunk in sufficient quantities and at proper 
times is of great value as a diuretic and as an aid to elimination. 
Soft water is to be preferred, and should be drunk freely at all times 
except during meals and for an hour after eating. The best results 
are obtained by drinking a given amount (four to eight, or more, 
ounces) every hour. As such a course is usually impracticable out- 
side of hospitals and health-resorts, under ordinary circumstances 



100 GENERAL THERAPEUTICS. 

two or three glassfuls may be ordered to be taken on rising in the 
morning and before meals. The free use of water, especially if iced, 
with meals is a fruitful source of indigestion as a consequence of 
the chilling and largo dilution of tho stomach-contents. The vicious 
habits of rapid eating and imperfect mastication of food may often 
be corrected by simply abstaining from the drinking of liquids during 
the Inking of food. 

Quinine, administered both as a ionic and an antiperiodic, is 
largely employed in cutaneous medicine for it- generally recognized 
systemic effects. It produces, in susceptible individuals, a peculiar 
smoothness and softness of the skin, which usually disappear when 
the drug is suspended. Like arsenic and iodine, it is occasionally 
ili<' cause of a generalized exanthem, and is capable of producing 
other toxic effects, Buch as failure of the heart's action, dizziness, and 
tinnitus aurium, symptoms recognized under the designation of cin- 
chonism. Tt will, of course, exhibit it- happiesl effects in malarial 
affections with coincidence of cutaneous symptoms and in diseases 
of the skin associated with a neurosis. The value of the administra- 
tion of the quinine muriate, in very large doses to the poinl of tol- 
erance, in some form- of general exfoliative dermatitis, is described 
in the chapter devoted to thai Bubject 

Salol. — This is a remedy of special value in many cutaneous dis- 
orders associated with intestinal Bepsis. It Is particularly useful 
in the forms of pustular acne when the subject of the affection lias 
an habitually coated tongue, a foul breath, and defective digestion. 
It is also of value in certain angio-neurotic disorders induced by 
intestinal putrefaction indicated by indicanuria. 

Ergot and Ergotine, whether by exerting an effecl upon the mus- 
cle-bundles or the vessels of the derma, or upon the uterus, or yet 
by influencing the general economy, are thought to possess some 
value in the treatment of several cutaneous diseases occurring in 
both sexes. Such are acne, purpura, and a few other disorders. 

Calx Sulphurata.- This sulphur compound was once regarded as 
the most efficient of its group for internal use in cutaneous diseases. 
Its supposed value in furunculosis has led to its employment also in 
eczema, acne, and impetigo. Tt is given in doses of from t\j (0.004 I 
to J (0.016) of a grain, three or four times daily. Tt i-. however, 
a remedy uncertain in operation and of dubious effect. 

Chrysarobin. — This drug has been administered internally by 
Stocquart 1 and others, in doses of & (0.01) of a grain, for a number 
of cutaneous disorders. 

Ichthyol, mentioned later as of some value when externally em- 
ployed, has also been given by the mouth. 

Jaborandi and Pilocarpine, probably as a result of the free dia- 
phoresis which they excite, unquestionably exert immediate thera- 
peutic effects in a number of cutaneous disorders especially the angio- 
neurotic group. 

'Annates, 1884, s. ii., v., p. 15, 



INTERNAL TREATMENT. 101 

Sulphur, highly esteemed as a popular remedy in cutaneous affec- 
tions, exerts but little influence upon the latter when it is ingested. 
Its cathartic effect is the chief reason for its administration. It is 
recommended by Crocker in some of the disorders of the sweat- 
function. 

Antimony in small doses is of unquestioned value in many dis- 
eases of the skin. It is, when not contraindicated, employed with 
advantage in psoriasis, pruritus, and some of the obstinate forms of 
eczema. 

Tar, Carbolic Acid, Creosote, Guaiacol, Resorcin, Turpentine, 
Copaiba, and Phosphorus. — These remedies have been employed in- 
ternally with appreciable effect in certain cutaneous maladies. They 
have been used with advantage in cases of lupus, eczema, psoriasis, 
and pruritus ; but the disagreeable effect of their internal administra- 
tion has been to a great degree a bar to their general employment. 
The " perles " of phosphorus and the elixirs of the same drug obviate 
this difficulty in the instance of at least one of these articles. Cre- 
osote carbonate given in capsules is usually well tolerated. 

Animal Extracts, Thyroid Extract. — These and other prepara- 
tions of the thyroid, adrenal, and other glands of the larger mammals, 
have in recent years been employed largely in various diseases of the 
skin. In myxcedema decided and brilliant results have been ob- 
tained, and they possess some value in ichthyosis, psoriasis, and 
a few tuberculous affections of the skin. The depressing action of 
thyroid-extract on the heart makes it an unsafe remedy to use 
except with caution. 

Maltine, and other preparations of malt alone or in the valuable 
combinations on sale, are of marked value in promoting the nutri- 
tion of the skin. They are especially indicated where there is im- 
perfect digestion of the carbohydrates, and where fats are not readily 
assimilated. They are useful in acne, in scleroderma, in syphilis, 
in tuberculosis of the skin, and in many of the cachexias accom- 
panied by cutaneous symptoms. 

Iron. — This metal and its several compounds are invaluable in the 
management of a long list of cutaneous disorders. Iron is indicated 
in many cases of cachexia and struma; in tuberculosis of the skin; 
in syphilis; in all the anaemias; and in many cases of purpura and 
pemphigus. Fortunately, iron is often well assimilated when com- 
pounded with other drugs, and hence has been suggested the long 
list of compounds of iron and mercury and of iron and iodine in 
syphilis; of iron and quinine and of iron and the vegetable bitters 
in anorexia and anaemia; and of iron with cathartics in atonic con- 
stipation. 

Analgesics have occupied a small space in cutaneous medicine, 
and that space should be more and more restricted. The use of 
acetanilid, of opium and its alkaloids, of phenacetine, of potassic 
bromide, of trional, of sulphonal, and of articles of the same class, 
has been indicated for relief of the tormenting pruritus, pain, and 



102 GENEEAL THERAPEUTICS. 

insomnia accompanying a long list of dermatoses. Unfortunately, 
most of the preparations devised to insure relief, after a temporary 
calmative effect have a decidedly aggravating influence upon the 
exanthem present. To a degree scarcely noticeable in other cases 
have drug-habits been formed in consequence of the temporary as- 
suagement of the local distress when under the influence of an anal- 
gesic. As a rule, the most competent physician is he who secures 
relief for his patient without narcotizing the nerves which are utter- 
ing their protest by abnormal sensation. The expert reserves for 
the last extremity an ordering of medicines of the anodyne clas- in 
attempting to secure relief. 

Hypodermatic and Intracutaneous Injections of alcohol, arsenic, 
mercury, cocaine, carbolic acid, the alkaloids of opium, antitoxins, 
exalgine, of erysipelas-toxins, and other substances have been largely 
employed in the management of cutaneous disorders, some with 
marked success, others with doubtful results. The most brilliant of 
the achievements in this direction are withoul question the relief of 
the Bjphilodermata by deep intramuscular injections of mercury. 
The injection of the antitoxins 1 which have been such a boon in an 
important group of general disorders has, on the whole, proved dis- 
appointing in cutaneous medicine. Attention has been directed to 
the special objections in most of the affections of the skin to the use 
of anodynes and opiated medicaments by whatever route introduced 
into the system. The temporary alleviation, when secured, is gained 
at too great a cost. 

Thiosinamine, Taurine, and yd other Bubstances have been injected 
subcutaneously in the management of Lupus, acne, eczema, psoriasis, 
lepra, and other affections. They have do! ;i- yel such an acceptance 
at the hands of the profession as would justify their employment in 
any save specially selected cases. 

Opsonins. — During the past few years opsonotherapy has at- 
tracted wide attention. In dermatology it is applied chiefly to in- 
fections induced by the staphylococcus and tubercle-bacillus. The 
chief disorders so treated are furunculosis, acne vulgaris, sycosis, 
lupus vulgaris, and scrofuloderma. Of those named above, lupus 
vulgaris seems most rebellious to the treatment. 

Literature. 

Hektoen, L. Phagocytosis and Opsonins. Journ. Amer. Med. Assoc, 1906; 
xlvi., p. 1407. An excellent exposition of the subject with full references to 
earlier work. 

Whitfield, A. The Opsonic Method in Skin Diseases. Translations of the sixth 
International Derm. Congress, 1908; pp. 273-283. 

Von Eberts, E. M. Bacterial Inoculation in the Treatment of Suppurati%e 
and Tuberculous Diseases of the Skin, after the method of Wright, 1908. Ibid., 
pp. 284-290. 

Schamberg, Jay, F., Gildersleeve, X., and Shoemaker, H., Bacterial Injections 
in the Treatment of Diseases of the Skin, 1908. Ibid., pp. 291-308 (with refer- 
ences and followed by discussion). 

1 See opsonins. 



INTERNAL TREATMENT. 103 

The method was largely perfected by Wright and Douglas of 
London. To be properly carried out much time and good laboratory 
facilities are essential. The method essentially consists in injecting 
hypodermatically definite quantities of sterilized cultures of bac- 
teria isolated from the affected patient. 

It is proven that the serum of the blood contains substances 
which render bacteria susceptible to phagocytosis by the polymor- 
phonuclear leucocytes ; these substances Wright termed opsonins. The 
term is derived from a Greek word meaning "to prepare food," 
'* to cook." As phagocytosis is the important feature in overcom- 
ing these infections, the quantity of opsonins becomes important. 

For comparison in the work, the quantity of opsonins in a normal 
individual is denoted by : 1. As a rule in an infected patient they are 
reduced to .3, .4, .6, or .8; in other words are less than normal (ex- 
ceptions to this occur). 

The opsonic index refers to the ratio between the amount of 
opsonins in the serum of an individual suffering with a bacterial 
infection and the amount in the serum of a normal healthy person. 

Wright says : " Vaccines are any substances that on being m- 
oculated into the body will cause the generation of a protective sub- 
stance." His vaccines consist of bacterial bodies. 

Two difficult problems are presented: first, the determination 
of the proper dosage, and second, the time-interval between the 
injections. 

Immediately following inoculation the amount of opsonins is 
diminished (negative phase). This period varies according to the 
size of the dose and other circumstances. This period is followed 
by an increase and by a rise in the index (positive phase). After 
a varying time, the index begins to fall again but does not descend to 
its former low level. Therefore, by properly regulating the size of 
the dose and repeating it at the right interval, the amount of protec- 
tive substances may be kept abundant as indicated by a high index 
and clinically by improvement in the symptoms. 

The Preparation and Standardization of Bacterial Suspensions for 
Therapeutic Injection. — The size of the dose in the therapeutic injec- 
tion should always be controlled by an approximate knowledge of 
the actual number of bacteria. 

The method of standardizing the suspensions as originally devised 
by Wright is to be recommended. 

It consists (1) of thoroughly mixing equal parts of an even, rather 
dense bacterial suspension in ISIaCl solution and a known blood; (2) 
of making and staining a thin smear; and (3) of determining the rel- 
ative number of red blood-corpuscles and bacteria in five or more 
fields under the 1/12 objective. From this the number of bacteria 
per c.c. can readily be determined. 

Example: — Suppose that in a given case the red blood-cells 
are five times as numerous as the bacteria. It is previously de- 
termined that the sample of blood used contains 5,000,000 erythro- 



104 GENEZAL THESAPEUT1CS. 

cytes per c.mm. Hence the number of bacteria is 1,000,000 per 
c.mm. or 1,000,000,000 per c.c. If 50,000,000 are to be injected one 
may inject 1/20 c.c. diluted with b.s. XaCl sol. 

Essentials in the Determination of the Staphylococcus Opsonic Index. — - 
(1) An even suspension in XaCl of a 24-hour culture upon agar of 
the proper density. This is best obtained by suspending some of 
the growth from agar slant and then centrifuging down the clumps. 
A 24-hour-old-broth culture also answers this purpose. 

(2) Washed leukocytes or washed blood for phagocytes. 

Ten or more drops of blood are obtained from a prick in the ear 
and suspended in a two per cent, sodium citrate solution contained in 
and nearly filling an ordinary electric centrifuge tube. Thia is then 
centrifuged thoroughly until both the red and white corpuscles are 
thrown down. The citrate solution is now poured or pipetted off 
and normal Nad solution added and the corpuscles suspended and 
then agiiin sedimented. This is usually repeated once more. The 
salt solution is decanted and the top layer containing a large per- 
centage of the white corpuscles is pipetted off and thoroughly mixed 
and placed in a small test tube. This is designated in general use 
as the "washed blood," "washed leukocyte-," "blood cream," etc. 

(3) The Sent. The k - normal pool '* of equal parts of three or 
more normal sera as well as the patient's serum are best obtained in 
small u-tubes from a prick of the finger or the ear. After five to ten 
minutes when clotting has taken place, the clol i- separated from the 
serum by placing the tubes in the centrifuge Bocketa and centrifug- 
ing for four or five minutes at high BpeecL 

The method of obtaining the hi 1 and mixing the three essen- 
tial factors by Wright's method j> complicated and requires not a 
little skill in preparing the necessary glassware. The method 
evolved in Hektoen's laboratory by the use of the simple tube mid 
a small capillary pipette which is bent at right angles, is simple as well 
as accurate. A special incubator i- entirely unnecessary. 

After mixing the pool of normal -era. a small amount is drawn 
up the capillary tube for a distance of apparently two inches. This 
point is marked with a glass pencil or a bit of India ink. A 
bubble of air is drawn in the end. When the washed blood, and 
in like manner the bacterial suspension, is drawn to the point 
marked above, in this way equal parts of the three necessary factors, 
(the serum, the washed blood, the bacterial suspension | are obtained 
and then thoroughly mixed by drawing them back into the wider 
portion of the pipette five or more times. The second pipette is 
now prepared. It contains the patient's serum, the variable factor. 
Both pipettes are now placed in the thermostat at 37 degrees and 
incubated for fifteen minutes. 

Smears are now made after mixing thoroughly and the average 
number of bacteria contained in at least fifty leukocytes determined. 
This indicates the relative opsonic power of the normal and patient's 
sera. 



INTERNAL TREATMENT. 105 

From this the opsonic index is determined by dividing the result 
obtained where the patient's serum was used by the result obtained 
where normal serum was used. 

For example : If the count where normal serum was used shows 
that an average of four staphylococci was taken up per leukocyte 
and where the patient's serum was used shows five ; the opsonic index 
of the former is normal or unity, that of the latter 5/4 or 1.25. 
Any of the polychrome blood-stains may be used to stain the smears. 
Two per cent, carbol-thionin solution in methyl alcohol is satis- 
factory. 

Spraying. — Spraying the skin for antiseptic purposes is of value, 
and may be often employed with marked advantage. The several 
solutions of formalin are best suited to the purpose. Frigorific 
sprays for the purpose of freezing a part of the skin selected for opera- 
tion, as in the case of epithelioma, are indispensable to the operator. 
Those chiefly employed are discharged from bulbs containing ethyl 
chloride. 

Natural Mineral Waters. — The chief value of many of the min- 
eral springs and health-resorts of the United States, lies in the change 
of manner of living that they invite and necessitate. Sunshine, pure 
air, recreation after the care and toil of business, change of climate, 
of foods and drinks, and even of cooks, often decide the question of 
speedy recovery. Unfortunately, both in America and in Europe, 
many of the health-resorts are peopled by unscrupulous charlatans, 
with a tendency to attribute all the benefits to be derived from these 
sources to the medicinal virtues of this or that particular spring, 
aided always by treatment according to their own peculiar methods. 
Many patients affected with disease of the skin are thus made worse 
by a temporary residence at noted health-resorts, and, therefore, it is 
often the case that a visit to the seashore, to the mountains, or to 
any healthful place in the country proves conducive to greater prac- 
tical results. None the less the springs of America and Europe 
having mineral constituents, in many instances supply a valuable 
means of treating cutaneous diseases. The sulphur waters of Rich- 
field Springs, of Sharon Springs, and of Avon Springs, in this coun- 
try, as of those of Europe, operate chiefly by an influence exerted 
upon the digestive tract ; the springs of West Virginia are examples 
of calcic waters having for the most part a diuretic effect. The fine 
water of the Poland Spring in Maine is chiefly valuable by reason of 
its remarkable purity. The alkaline waters of Colorado Springs, of 
Saratoga, and of other sources in America are rapidly securing a 
reputation equal to that of the famous Vichy, Carlsbad, and Ems of 
Europe. 

The chemical laboratories, however, are fast placing at the dis- 
posal of the consumer the salts, either natural or artificially produced, 
which represent the constituents of most of the mineral waters highly 
esteemed both here and abroad, in the management of disease. In 
this way the Apenta, Hunyadi Janos, Hathorn, Kissengen, Congress, 



106 GENERAL THERAPEUTICS. 

Friederichshall, Rakoczy, and other waters may be produced at will 
by solution of the proper salts in water: and the latter in many of our 
large cities is now furnished after distillation and aeration in such 
purity that it competes with distilled water in the laboratory of the 
chemist and in the operations of the photographer. 

Of the chalybeate and arsenical waters, the former abundant in 
Michigan and New York, the latter best represented by that of Levico, 
in the Austrian Tyrol, it may be said that their use is often followed 
by excellent results, especially when the drinking of the water is 
associated with the tonic regimen and healthful environment of the 
springs from which these waters are obtained. 

EXTERNAL TREATMENT. 

In the externa] treatment of diseases of the skin the indications 
are to hasten repair when this is possible; to alleviate distress if pal- 
liatives only are admissible; to destroy absolutely or excise the dis- 
eased tissue when this is justifiable. The following are the principal 
substances employed as externa] applications: 

Water, either pure or medicated by holding substances in solution 
or mechanical suspension, is applied either in baths or as lotions. 
Baths, local or general, may be employed for days continuously or but 
for a few moments al a time. They are given with water varying in 
temperature — cold, warm, or ]i<>t. Rain-water is to be used when 
practicable. 

Cold baths of short duration are generally followed by a sharp 
read ion. the skin becoming congested alter the normal temperature of 
the surface is regained. It is for this reason that cold sponging of 
the inflamed skin is usually grateful so long as it is continued, and 
is succeeded by an aggravation of the symplonis which it was intended 
to relieve. Continuous applications of cold water are not open to this 
objection. 

Hot baths are followed by a more or less enduring relaxation 
of the integument, while tepid water-baths are chiefly macerative of 
the surface. Hot baths are valuable in several of the exudative 
and hypertrophic affections of the skin. The application of watery 
lotions to the broken surface of the skin is likely to be followed by 
endosmosis, unless the specific gravity of the serum of the blood and 
that of the fluid of the bath or the lotion are nearly the same. This 
imbibition of fluids by the broken skin is accompanied by slight 
swelling of the tissues and is productive of disagreeable sensations. 

The continuous warm water-bath in which the patient is immersed 
either for the greater part of a day or for a few hours at a time is an 
exceedingly valuable means of treating pemphigus, the severe grades 
of burns, and ulcerative affections of the skin. 

The most perfect of all applications of water to the surface of the 
body is that most resembling the water-bath in which the tender skin 
of the foetus is immersed for consecutive months. Here the bath is 



EXTERNAL TREATMENT. 107 

continuous ; the temperature is that of the viscera of the living 
animal ; and the delicate skin of the unborn child is anointed with a 
fatty substance which interferes with the macerative action of the 
surrounding fluid so long as vitality is preserved at the average 
standard. The comfort and therapeutic value of a bath prepared 
and administered in approximation to this ideal can scarcely be 
overestimated. Were it not for the difficulties with which it is at- 
tended, so far as relates to many portions of the surface of the body, 
it would be possible with this single therapeutic measure to rob the 
exudative affections of the skin of many of their formidable features. 

Vapor, steam, Russian, and Turkish baths are less valuable than 
is usually supposed in diseases of the skin. The macerative effect 
they produce is not always desirable. They possess some value in 
severe general pruritus, in ichthyosis, and in keratosis pilaris. 

In acute inflammations of the skin the application of pure water, 
even when of proper temperature, is often prejudicial to the integu- 
ment, and soap-and-water washings may prove quite harmful. The 
greatest caution must be exercised in giving instruction to patients 
as to the washing of the inflamed skin. 

Water for external application, as in the bath, is medicated by 
the addition of a large number of substances, such as marine salt, 
boric acid, corrosive sublimate, sodic and potassic salts, alum, tannin, 
the mineral acids, gum Arabic, gelatin, and bran. 

The alkaline bath, made by adding sodium bicarbonate or biborate 
to water having the proper temperature in the proportion of 12 ounces 
of either salt to 30 gallons, is usually grateful to the inflamed skin. 
Sulphur-baths are best prepared by adding an ounce of Vleminckx's 
solution 1 to the above-mentioned quantity of water. 

Baths Sulphur-baths.' — The natural sulphur-baths of Richfield 

Springs and Avon Springs, in this country, are efficacious in certain 
cutaneous affections accompanied by roughness and thickening of 
the integument. 

Tar-baths. — Tar-baths are usually given by first anointing the skin 
of the patient with the tarry substance to be employed, and by im- 
mersing the body in warm water for some hours afterward. The re- 
sulting effect can usually be accomplished as well by other measures. 

Salt- and Marine Baths, possess the highest value with respect to 
the general health of the individual; and are advantageously em- 
ployed over the body-surface when, for example, the head alone is 
affected with a dermatosis (rosacea, acne, erythema), and when the 
salt is not brought into contact with the morbid surface. In very 
many cases a sea- or salt-bath produces aggravation of a cutaneous 



M. 



le formula is: 






5 Calcis, 


3 SS > 


16 


Sulphur, sublim., 


lr, 


32 


Aq. dest., 


3 x ; 


320 


Coque ad ^vj [200] deinde filtra. 






Sig. " Vleminekx 's Solution." 







108 GENERAL THERAPEUTICS. 

affection, and indeed, in some cases, is capable of begetting the same. 
A properly directed salt-bath or lotion, however, is at times positively 
beneficial, not merely in chronic, but also in acute affections of the 
skin. 

The strength of the usual marine salt-bath is \ pound to the gal- 
lon, though 10 pounds of the salt are often added to 25 gallons of 
water with advantage. The sea-sail is nol preferable to the article 
obtained from the natural brine-wells of the interior of the country. 
For invalids the skin of the body may first be well rubbed with the 
finest table-salt well warmed in an oven, after which a tepid or warm 
bath may be used to cleanse the surface. 

Antiseptic Baths. — These baths are most often employed by the 
surgeon. In the managemenl of skin-affections local baths of boric 
acid in hot or cold water may be employed. The acid is soluble in 
about 25 parts of cold water. ( lorrosive-sublimate baths are employed 
in the strength of 1 drachm I L) of the mercurial to 30 gallons of 
water. Local baths thus medicate d are often employed in the cleans- 
ing of ulcerated and suppurating surfaces with a view to subsequent 
dressing. 

When employed as a lotion, water is made to produce a sedative 
effect by the addition of opium, belladonna, glycerin, carbolic acid, 
hydrocyanic arid, sine, bismuth, mercury, lead, and alkaline bicar- 
bonates with the sodic biborate. [I is rendered stimulating by the 
admixture of alcohol, mosl of the acids and alkalies in stronger boIh 
tion than in the soothing or sedative lotions, and also by a large num- 
ber of substances which operate upon the surface either mechanically 
or chemically. Water i- also rendered astringenl when tannin, lead, 
and similar medicaments are dissolved in ii : and by its union in 
various proportions with soaps and alkalies a solvenl effed is pro- 
duced, either upon the cuticle itself or upon pathological or foreign 
products upon it- surface. 

Soaps.- Sofl soap (sapo viridis, sapo mollis) made by the addi- 
tion of caustic potash in an excess of between 3 and 1 per cent, to an 
animal fat, ia a substance exceedingly useful in the treatment of -kin 
diseases, h is used for the purpose of producing either a detersive or 
stimulating, and at times a slightly destructive effeel either upon the 
surface of the skin itself or upon pathological accumulations upon the 
surface (crusts, scales, etc). Tt may be used aa a plaster or with 
water: and this last either in substance or by the aid of the widely 
known "Spiritus Saponis Alkalinus" which Hebra firsl devised: 2 
ounces (64.00), of green soap to 1 ounce (32.) of alcohol, ft 
with spirit of lavender. The hard or soda soaps are employed 
chiefly for toiler purposes. 

" Over-fatty " or " superfatted " soaps, both soda and potash soaps, 
are neither alkaline nor neutral in reaction, but contain a slight ex- 
cess of unsaponifiod fat. They are exceedingly mild in their deter- 
sive action upon the skin, though the lather produced in their use is 
not so abundant as that with the alkaline soaps. These are usually 
proprietary articles. 



EXTERNAL TREATMENT. 109 

Medicated Soaps, containing carbolic acid, glycerin, tar, sulphur, 
and various oils, are sold in the shops; hut they usually contain so 
small a portion of the individual medicament from which each is 
named that they are practically worthless except for purposes of ablu- 
tion. Under cold pressure they may be made to contain medicinal 
substances in therapeutic proportions, but other forms of administra- 
tion of such medicaments are preferable. 

Fatty and Oily Substances are applied to the skin either directly 
by pouring, or by friction, or by the mediation of compresses, ban- 
dages, etc., which are saturated or are spread with the material to be 
applied. The oils may be used for either nutritive, soothing, or stim- 
ulating effects. To the first and second classes belong cod-liver, lard, 
olive-, almond-, linseed-, neat's-foot, castor-, and similar oils; to the 
third class belong the oil of tar, of cade, of white birch, of the cashew- 
nut, and of juniper. 

Fatty substances are also applied in the form of ointments or 
pomades. They are compounded with various medicinal substances, 
according to the requirements of each case, such as the salts of mer- 
cury, zinc, copper, lead, and sulphur; pyrogallol, chrysarobin, car- 
bolic and hyposulphurous acids ; tar, camphor, iodoform, balsam of 
Peru, chloral hydrate, and the extracts of opium, belladonna, etc. 

Vaselin. — The products of petroleum refinement represented by 
this ointment, though not true fats, are employed increasingly for 
similar purposes. They are particularly useful as bases for ointments 
for application to the hairy portions of the body, such as the scalp, 
where more consistent salves paste the hair to the surface in an un- 
sightly mass. 

In the class of soothing ointments which are required in many 
cases in which the skin is the seat of a severe pruritus or of burning 
sensations, may be named the diachylon, benzoinated zinc-oxide, 
" cold-cream," lanolin, cucumber, petroleum, spermaceti, cacao- 
butter, and olive-oil with vaselin ointments. Those medicated with 
the several oleates and with the salts of bismuth, zinc, or lead, are 
often of great value. As a rule, however, in most cases calling ur- 
gently for soothing applications fat-containing dressings are not to be 
preferred to lotions or dusting-powders, or the two last named in 
combination. Ointments are rubbed gently over the affected surface, 
but they are more efficient when spread on bits of soft muslin and kept 
in contact with the skin. 

McCall Anderson's ointment has long been employed for soothing 
inflamed surfaces. It is compounded by adding 1 drachm of bismuth 
oxide (4.) to 1 ounce (32.) of oleic acid, 3 drachms (12.) of white 
wax, 9 drachms (36.) of vaselin, and a few minims of the oil of roses. 
10 parts of lanolin, with 20 of lard and 30 of rose-water, make another 
useful combination. Many of these ointments have been found to 
be irritating on account of the fatty acids which they develop, espe- 
cially in hot weather. They may be kept sweet by the addition of a 
small quantity of formalin to each jar compounded! 



110 GENERAL THERAPEUTICS. 

The following formula are also useful : Boric acid, white wax. and 
paraffin each 10 parts; oil of sweet almonds, 60 parts (H. Hebra) ■ 
Bismuth oxide 1 drachm (4.) ; white wax, 6 drachms (24.) : vaselin 
and olive-oil of each 1 ounce (32. ) ; Boric acid, 1 part ; glycerin A 
parts; anhydrous lanolin, 5 parts: vaselin, 70 parts (bullring's 
boroglvcerin eream ointment"). Other fatty applications are pre- 
pared by adding olive-, sweet-almond, or cotton-seed oil, as well as 
Jardand lanolin, to lime-water in nearly equal proportions. These 
furnish a thick emulsified substance which requires to be well shaken 
before application. Any one of these emulsions may 1,, medicated al 
™W the , afl [ ll . t,on °/ rinc > bism »th, calamine, or other insoluble 
ra^nce which is mechanically mixed with the fatty emulsion when 
ino whole is well shaken. 

Stimulating ointments are usually made by the addition of such 
substances as tar mercury, resorcin, salicylic acid, pyrogallic acid 
chrysarobm, or sulphur to any one of th reral salv/baL in cW 

limii use. 

llsll ^ Cerin ' even *■*■*■ <■*« ••MTli-l in iti purity to the skin is 
'"" f> lr "teting. Tt l8 , however, exceedingly useful when diluted or 
1 ". :| ; " f component part of lotions and ointments. When combined 

ZZ^T 7 m ^ erent P~P° rt j 0M ^ m^es a series of combinations 

known as glycerol**, or glycerolates. Tl combinations are pasty 

semisolid substances which aw capable of varied medication, as n fa 

^Zt 7 U] T: UiU - n^WMrfW chiefly as pro tivet 

of the slnn*urface. Glycerin, used in a fluid soap, is an exceedingly 
& nt when a milder effed d than that produced by 

d .sunt,, soap describ, , !lllllVl , The Vienna preparation known as 
S"*' 1 "-" 1 "*? l8 * D a i^«Me substitute of this sort when s sofl 
shampoo is required for the --alp. 

*j^«apl<7ed for local application in , ftheakinhaye 

greatly been perfected by Lassar and Unna J 

wl • V"T ***** : "; ' ralu l ble "I i:,llv in ,}, «- exudative affections, in 

I ul n Z V ri , " ll,r ^ r' 11 to,erated *' r "*»*"* P«™ b* 

"rowt in TIl ° ?***' When a PP lied T " ~ 1 "- 1 ' ****"»> form a 

protective and adhesive dressing, which may 1,. medicated as desired. 
Une of the best and most serviceable i i 

5 Zinc. Btearat cum acetanili.] 1 

01. oliv.. ■' ' -. ... 

Unguent, aq. rus., J '''' ^ 

Or the following modification of L 

5 Zinci oxidi, "» 

Talc. f aa 3i j : 

Acid, salicylic.. 

YaseliD - £,"' 16| 66 m. 

fW^L?"5 ° f ] f D0lin ' VaSelin ' tale - and zinc oxi de form a base 
that is suffer than the preceding and adheres better. To the<e bases 
may be added various remedies in desired proportions. 
1 Monatsbefte, 1884, iii.. p. 38. 



It 



EXTERNAL TREATMENT. Ill 

Duhring's modification of the original Lassar paste is: boric acid, 
9j (1.33) ; starch and zinc oxide, each 5ij (8.) ; vaselin, §j (32.). 
Unna employs: starch, 3 parts; glycerin, 2 parts; water, 15 parts; 
boiled down to 15 parts. Half the quantity of any desired medica- 
ment may be added to the amount ordered. Paraffin may be added 
in the making of very stiff pastes in the proportion of equal parts of 
this substance and water; twice the quantity of lanolin; and about 
%5 of white wax. 

Other pastes are prepared with kaolin (terra alba, or Armenian 
bole, of red color when it is desirable to have the application resemble 
the color of the skin), gum, lead, dextrin, glycerin, and other sub- 
stances. Formulae for each are appended. 

Kaolin in a pure state, with equal parts of vaselin or glycerin, or 
with almond-, olive-, or linseed-oil, in the proportion of two to one, is 
readily applied in a thin layer over the skin. 

For making lead-pastes, litharge is boiled with twice the quantity 
of vinegar until the latter has evaporated and there is left a damp but 
drying paste, which on occasion, may be remoistened with a small 
quantity of vinegar. 

5 Lithargyr. subt. pulv., 3jss; 451 

Aceti, Bijss; 75 1 

Coque usque ad consistent, pastse: deinde adde ol. lini [v. glycerini, v. ol. 
olivse], 10.— M. 

In the two forms of paste above described the adhesive and desic- 
cative qualities are obtained from the main ingredients, but in those 
resulting from combinations of gum, starch, and dextrin these results 
are for the most part obtained by the addition of other ingredients, 
such as sulphur, zinc, etc. A good basis, semisolid, rapidly drying, 
and fixing its ingredients well upon the surface, is the following : 

^ Zinci oxidi, 3jss; 451 

Acid, salicylic, 3ss; 2| 

Amyli oryzae, \ 

Glycerini, J 

Aq. dest., 
Coque ad., 3"ivss (145). 

For a sulphur-paste : 

]£ Sulphur, prsecipit., 

Cale. carb., 

Zinc, oxid., 

Amyli oryzse, 

Glycerini, 

Aq. dest., 
Coque ad., 3"iv (120). 

To make use of dextrin, the official pulverized article is selected, 
and a simple paste of this forms a good drying base. An added half- 
weight .of glycerin is required if powders are also combined with the 
paste — e. g.; 



aa 3iij; 


12| 


SiJ ss ; 


75| 


SJss; 


451 


3ss; 


2 


^ss; 


15 


3iij; 


12 


^ss; 


15 


Bijss; 


75 



112 



GENERAL THERAPEUTICS. 



fy Zinc, oxid., 

Dextrin., j 

Aq. dest., / 

Glycerin., 

Sulphur, sublim. [vel 90<L 
sulpho-ichthyol.], 
Coque. 



JB& Jss; 



A mixture of dextrin and lead U thus prepared 



# Lithargyr., 

Acet., 
Coque ad remanent., 50. 
Adde: 

Dextrin. 



Coque. 



Dextrin.. | 
Aq. dest., J- 
Glycerin., J 



3-; 



45| 
15| 

45| 
2| 



15| 



If too consistent, these pastes are made t.. spread easily by the 
addition of a fW drops of hoi rater. 

For gum-pastes, -him Arabic ie used in the proportion of 1 part 
of the mucilage and glyo rin to 2 parte of the powder selected, mixed 

with. nit heal ( . '/. : 



K" Zinc, n\ii]., 

Bydrarg oxid. rob 
Mncilag. .'.■ 

<:i\ >< ri ii., / 

K < n t. pnepuml., i 
Bolphur. Kiililim., i 

I'ii'is liquid., 
J li. 

MlK'i!:. _■ 

Glycerin., / 



K \.-i«i. mlicylic. 
< Hjeerin., 
Ifucilag. acne., 
OL ricini, 





is 




2 




15 



II 



.^'.1 



.**»; 



15| 
15| 



| M. 



Tin- following details are t.. 1m- noted respecting the availability of 
these pastes for different Ingredients: Lead i- besl used a- an ao I 
either in a Bimple paste or with dextrin, the carbonate, oleate, and 
iodide combining well with both. Zinc oxide and sulphur combine 
well with kaolin, had. starch, dextrin, and gum. Sulphur coml 
well with the three last named, poorly with kaolin, and not at all with 
lead. Ichthyol suits well with all save the gum-pi -"• -. Naphthol, 
cah unci, corrosive sublimate, rod and white precipitates, carbolic acid. 
chloral hydrate, eamphor. and salicylic acid can be incorporated with 
all. the last named in smaller proportion with crum-paste. Tar is 
better united with starch, dextrin, and £rum than with the others 
Iodine and iodoform naturally do not suit well with the starch- and 
dextrin-pastes. Chrysarobin and pyro^rallol are united with kaolin 
and gum-pastes, and should not be added to them. Fattv and soapy 



EXTERNAL TREATMENT. 113 

substances, if commingled in large amounts with these pastes, injure 
their special properties. 

Glycogelatins are useful for protecting a surface and excluding 
the air. They are made with varying proportions of glycerin, gelatin, 
zinc oxide, and water. When cold they are solid, but when melted on 
a water-bath can be painted readily over a surface, upon which on 
cooling they form an adherent protective coating. Before the gelatin 
has hardened on the skin it is well to pat it with cotton, or to lay over 
it a piece of thin gauze or muslin to form an additional protection and 
to prevent the paste sticking to the clothing. A firm but soft and 
flexible gelatin is made by mixing on a hot-water bath 1 part of zinc 
oxide, 2 of gelatin, 3 of glycerin, and 4 of water. More gelatin in the 
preparation makes it firmer and causes it to dry quicker. A greater 
proportion of glycerin, on the other hand, interferes with the complete 
drying of the surface, but makes a softer preparation, more acceptable 
to some skins and very useful where a bandage can be applied. Zinc 
oxide helps give body to the gelatin, but if used in too large propor- 
tion interferes with the coherence of the preparation, so that it cracks 
when dry. To the glycogelatins may be added white precipitate, 
sulphur, ichthyol, thiol, chrysarobin, iodoform, or other antiseptics. 
Some drugs, as salicylic acid, resorcin, naphthol, and carbolic acid, 
tend to destroy the coherence of the gelatin. Fox says that this ob- 
stacle may be removed by adding to the paste 5 or 10 per cent, of 
fresh lard. 

Varnishes, containing glycerin and a single gum, are often very 
serviceable in protecting the skin. They are especially useful on the 
face, as they are transparent and inconspicuous. 

Pick's varnish (linimentum exsiccans) is made as follows : 

]£ Tragacanth, 5 parts. 

Glycerin, 2 parts. 

Distilled water, 93 parts. 

The tragacanth is soaked in a portion of water from ten to twelve 
hours and triturated to a perfectly smooth mass before adding the 
glycerin and other ingredients ordered. The jelly may be prepared 
without delay by triturating the tragacanth with boiling water, but 
the result is not so good. 

This jelly is applied without heating and quickly dries on the 
skin. An improvement on this varnish is Elliott's bassorin paste, 
which keeps better than the former. The formula is as follows : 

]£ Bassorin, 
Dextrin., 
Glycerin., 
Water to make 

This should be kept in a tightly closed jar, as it dries rapidly on 
exposure to the air. Like the other pastes, it not only serves as 
a protective coating, but also as a base for the application of other 
remedies. 

8 



SJss; 


45 


3vj; 


24 


3ijss; 


10 


S"j; 


90 



114 GENERAL THERAPEUTICS. 

Powders are mechanically dusted over the surface of the skin 
for the purpose of protecting it, and occasionally, also, to produce 
an astringent or antipruritic effect. To be serviceable, they should 
generally be rendered impalpable by sifting them carefully through a 
fine silk bolting-cloth. They are composed of starch, talc, magnesia, 
lycopodium, calamine, bismuth, boric acid, the several stearates, cam- 
phor, tannin, zinc oxide, iodoform, rice, kaolin, magnesium silicate, 
orris root, salicylic acid, aristol, curophen, and similar subs'tances. 
The articles sold by grocers as "gloss starch" and "corn-starch fa- 
rina" are usually much mure finely bolted than the dusting-powders 
extemporaneously prepared by chemists. All starchy substances are 
open to the objection of forming little pasty rolls or "cakes" when 
wetted with serum or with sweat. Lycopodium, which consists of 
irregularly shaped globular pollen-sporules, never behaves in this 
way, ami is, for thai reason, deservedly popular. Zinc-stearate with 
acetanilid is excellent for similar reasons, and when dusted on the 
surface forms a dressing impervious to moisture. 

Medicated powders may be first dissolved in alcohol, ether. or 
chloroform. The solution is then mixed with Btarch or with French 
chalk. Evaporation of the menstruum is conducted without artificial 
heat, and m fine Btarch or chalk-powder results. 

For absorbent purposes Grundler 1 has shown that by far the most 
effective powder is magnesium carbonate. 

Plasters are employed when it is desired i" exerl a more or less 
continuous effect upon the skin, and are thus necessarily consistent 
and desirable. The resin-plasters are less useful in -kin diseases be 
cause more irritating than the lead-plasters. In the zinc-oxide adhe- 
sive plaster the irritating effects of the resin have been entirely 
come, and the result is a plaster which has excellent adhesive qualities 
and which rarely chum- irritation even t<. sensitive skins. It thus 
answers admirably where simple protection is desired, and may be 
safely employed in order to retain other dressings in place. Onna's 
plaster-mulls are described below. The mercurial plasters are useful 
especially in syphilitic lesion- of the -kin. 

A valuable addition to the list of methods for applying medicated 
ointments to the skin has been devised by CJnna. Hi- Salve-muslins, 
or salve-mulls, are strips or bandages of muslin thoroughly impreg- 
nated and thickly spread with ointments medicated with almost 
desirable substance, from zinc-oxide to tar. thymol, salicylic acid, and 
mercury. They are elegantly made, and when exported are sur- 
rounded by impermeable tissue, so that they remain fresh and 
for several weeks, or even for months if kept in a cool place, but de- 
teriorate rapidly if exposed to the air of a warm room. They are 
efficacious, and, as a rule, well liked by patients. They are available 
in skin diseases of the exudative class affecting the extremities, but 
should be avoided when not recently prepared. 

TJnna's Plaster-mulls seem to be less useful. They are pla 
1 Monatshefte. 1888, vii., p. 1029. 



EXTERNAL TREATMENT. 115 

thinly spread on gutta-percha cloth, and manufactured with a wide 
range of medicinal constituents. They serve a good purpose in the 
protection of parts of the skin exposed to friction. 

Salve-pencils (Stili unguentes) and Paste-pencils (stili dilubiles), 
the latter destitute of fat and soluble when moist, the former insol- 
uble in water and compounded of fatty substances, are pencil-sized 
crayons made with wax, gum, and starch, for application to limited 
areas of the skin. The several mercurials, arsenous acid, cocaine, 
salicylic acid, and other medicaments may be applied in this way to 
the surface. 

Poultices. — These are not often ordered in the management of 
diseases of the skin, except for the purpose of softening crusts with a 
view to their removal. They are made, both warm and cold, with 
linseed-meal, potato-starch, bread and milk, oatmeal, and cornmeal. 
These applications are objectionable in all conditions in which a 
macerative effect of the epidermis is produced; and also in which 
micro-organisms may find a culture-field in the mass of the poultice. 
Poultices, in any needful case, may be made antiseptic by the addi- 
tion of formalin, boric acid, or mercuric chloride. 

Lanolin, or wool-fat, was first introduced as a salve-base by Lie- 
breich, of Berlin. It is a substance obtained from keratinic tissues, 
and contains cholesterin-fat instead of glycerin, with but 30 per cent, 
of water. It has a bright-yellowish color, a distinct odor of the sheep, 
and is neutral; when pure it is never acid in reaction. The refined 
product is free from cholesterin compounds and requires no fatty 
addition. This substance is readily absorbed from the surface of the 
skin, and, either pure or medicated, may be regarded as a useful addi- 
tion to the bases of -ointments. The adeps lanse answers the same 
end. 

Oleates. — The oleates of zinc, mercury, copper, lead, and other 
metals have been employed with advantage in the topical treatment of 
disorders of the skin. Of these, the oleates of mercury and of lead are 
decidedly the most valuable. The latter is represented by Hebra's 
white diachylon ointment. The mercuric oleate is serviceable in 
syphilitic, parasitic, and other disorders. 

Vasogen. — These products bid fair to supplant the oleates in their 
ready absorption from the skin-surface. In mercurial inunction 
vasogen-mercury capsules supply the exact amount required for 
employment at each sitting. 

Collodion and Traumaticin are employed for the purpose of ap- 
plying a remedy to the skin, and at the same time for protecting or 
contracting the surface to which the application is made. Traumati- 
cin is the name given to a solution of gutta-percha in chloroform, in 
the proportion of 10 per cent. In this way bismuth, cantharides, 
sulphur, chrysarobin, zinc oxide, white precipitate, iodine, and other 
substances may with advantage be applied to the surface, and the 
action of each be definitely limited to the margins of a single patch 
of disease. 



116 GENERAL THERAPEUTICS. 

Tar. — Tar in its several varieties, crude and distilled, together 
with its derivatives, occupies an important place among efficient top- 
ical agents. In general, it seems to exert upon the epidermis a local 
influence, which extends more deeply as the remedy is continuously 
applied. At times both irritative and inflammatory effects are thus 
induced, and even systemic intoxication when absorption from the 
skin occurs. Pix liquida, or the oleum picis, is the favorite article of 
this group with most American physicians; but the oleum cadini, or 
oil of juniper, and the oleum rusci, or oil of birch, are rather more 
generally employed by experts. The last-named, found in purity and 
abundance and to be had al a Low price, is recommended above the 
others. In Vienna the distilled oil is preferred, bul there is good 
reason to believe thai the crude oil is more efficacious. 

The skill of a physician Intrusted with the management of a dis- 
ease of the skin mighl almost be measured by his success in the use of 
far. He who has not lia<l experience in it- employment ia urgently 
advised to selecl one member of the tar-family and learn thoroughly 
how to apply that, Bingly and in combination, either as a lotion or in 
salve. Properly employed, it will favor involution of lesions, lessen- 
ing hyperemia, infiltration, scaling, and discharge. It serves ad- 
mirably as an antipruritic. It may, however, produce severe inflam- 
mation of the skin. 

To produce the benign <>r emollient effects of tar, it is besl mixed 
with seme soothing or astringenl powder, and with this end in view 
nothing ia better than chalk. Spender'a hints 1 for making auch an 
ointmenl are admirable : Finely levigated chalk ia at re wed into melted 
lard in a st^ne jar. the whole being Btirred until it is cold. Then at 
firal the smallest quantity of tar sufficient to make a browni-h smear 
of color is added to the quantity of salve employed for use. Tin- 
color can be Buocessively deepened at will. Auspitz advises the use 
of the tare in a pure state, applied in very small quantities with a 
strong bristle-brush and well rubbed in. In combination with <>n<' of 
the mosl valuable of all substances for topical use in cutaneous thera- 
peutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson 
salve modified (q. v.) represents such a combination. 

A group of Bubstances which occupy a therapeutic position in- 
ferior to the tars, but which serve an important end in the manage- 
ment of cutaneous diseases by the production of similar effects, are 
carbolic acid, creosote, salicylic acid, benzol, naphthol, iodol, thiol, 
chrysarobin, pyrogallol, resorcin, and jequirity. 

Ichthyol, fish-oil, introduced to the profession by Unna, is the 
distillate of a bituminous and sulphurous deposit of petrified fishes 
and marine fossils found in the Tyrol. Its chemical formula is 
C 26 H 36 S3Xa 2 6 . It has a tarry appearance, odor, and consistency. 
It is soluble in water, partly so in ether and alcohol, and can be 
incorporated in any desired proportion with fat, vaselin, and lanolin. 
It has been used both pure and diluted ; and several proprietary 
J Practitioner, June, 1883, p. 402. 



EXTERNAL TREATMENT. . 117 

articles (plasters, soaps, salves, and medicated cotton) are in the 
market. It has been used both in America and in Europe in cases of 
leprosy, pruritus, acne, sycosis, eczema, psoriasis, and a number of 
other cutaneous disorders. 1 It is used in solutions of from 10 to 50 
per cent, and in salves of from 5 to 20 per cent, strength. As before 
stated, it is also administered internally, more particularly in the 
management of rheumatism, in doses of from 15 to 20 drops. It does 
not seem to have a disturbing effect upon the stomach. 

Unpleasant results have been reported as following its application 
in a single instance (Sinclair). A four months' old infant sank into 
a stupor two hours after its head and limbs were smeared with a 
salve composed of one part of ichthyol to five of vaselin. 

Thiol makes an excellent substitute for ichthyol for most purposes, 
and lacks the unpleasant odor of the latter. 

Resorcin in ointments of the strength of from 5 to 20 per cent. 
serves as an antipruritic and alterative. Stelwagon reports an ano- 
dyne effect following its use. The same experimenter has modified 
Ihle's formula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms 
(4.-8.) of castor-oil, 5 minims (0.33) of Peruvian balsam, and 4 
ounces (120.) of alcohol, for use in alopecia and seborrhoea of the 
scalp. It is a valuable parasiticide in lotions of the strength of from 
5 to 10 per cent., and is especially useful in disorders of the scalp 
due to seborrhoea. 

Naphtol, or ^-naphtol, as it is termed chemically, first introduced 
by Kaposi, is chiefly valuable in scabies, but has also been used in the 
management of eczema, psoriasis, and other exudative affections. Van 
Harlingen 2 has found it to answer well in seborrhoea of the scalp. 
Neisser has described renal disorders as resulting from its use in 
children, but MM. Josias and Nocard 3 report that in ordinary medi- 
cinal doses it is harmless. The fact that the naphtol preparations are 
odorless and do not stain the sjrin is to be set down in their favor. 

Naftalan. — This is a distillation product from crude nafta that is 
found in the Caucasus. It is a thick fluid of dark green color 
and contains two and a half to four per cent, of soap. It may be 
mixed with powders, thus producing an ointment of any consistency. 
It is advised in inflammations of the skin accompanied by moisture. 

Boric Acid is of great value in diseases of the skin and is exten- 
sively employed as a lotion and in ointments and powders. As a rule, 
it exercises a sedative effect upon the surface to which it is applied. 
Over mucous surfaces it is occasionally a source of moderate irritation. 

Salicylic Acid operates especially upon the keratinized tissues of 
the epidermis, softening and separating the external portions of the 
horny layer from its deeper connections. For this reason it has a 

1 See Baumann and Schotten, Monatshef te, 1883, ii., p. 257 ; TTnna, Ibid., 1882, 
i., p. 225; Deut. med. Zeit., 1883, iv., p. 217; Samml. klin. Vort., 1885, No. 252;' 
Lorenz, Deut. med. Wchnschrft., 1885, xi., p. 627; Stelwagon, Jour. Cutan. Dis., 
iv., p. 326, Zeisler, Chicago Med. Jour, and Exam., 1886, liii., p. 32. 

2 Amer. Jour. Med. Sci., 1883, n. s., lxxxvi., p. 479. 

8 Annales, 1885, s. ii., vi., p. 257. 



118 • GENERAL THERAPEUTICS. 

special value in all the hyperkeratotic dermatoses. In somewhat 
weak strength it is employed as an antipruritic agent. It is most 
often employed in salves or pastes but is also used in lotions, being 
soluble in 2.5 parts of alcohol, 2 parts of ether, or 450 parts of water. 
It is a common ingredient of most of the popular corn- and wart-cures. 

Carbolic Acid, since in value as an antiseptic it has been largely 
surpassed by other articles, is chiefly employed to-day upon the skin 
as an antipruritic. It is applied in the form of lotion, salve, and 
paste, but much more often in lotions having the strength of from 
10 to 20 grains to the ounce (0.66-1.33 ad 32.). Other acids — nitric, 
sulphuric, lactic, acetic, muriatic, benzoinic, tannic, chromic — are em- 
ployed either for caustic, destructive, or stimulating effect, usually in 
liquid form. Tannic acid, however, is occasionally employed as a 
powder, in which form its astringent quality is combined with ihe 
soothing or antiseptic effect of other substances in powder. 

Chrysarobin, Pyrogallol, and Anthrarobin are useful aa cutan- 
eous stimulants capable of determining in the skin t<> which they are 
applied a characteristic dermatitis limited to the site of ihc applica- 
tion. Chrysarobin is especially useful in the local treatment of 
psoriasis, lepra, and the disorders due to vegetable parasites. It is 
employed in from 1 to 10 per cent, strength, in salve, lotion, or in 
collodion or traumaticin. A useful combination in the parasitic dis- 
orders of the scalp due to the tnicrosporon Audouini or to the tri- 
chophytons, is a solution of chrysarobin in oil of turpentine, about 1 
part in 250. A chief objection to it- use i- 'lie consequent staining 
of the skin and articles of apparel. < >n the Bcalp the hairs are turned 
to a yellowish-green -hade. Pyrogallol oxidize- after exposure and 
turn- the skin a blackish color. It is useful in mat { lichen 

planus, eczema, and the diseases due to the vegetable parasites. 1* 
has been employed in the Btrength of ."at per cent, in the removal of 
epitheliomata. Anthrarobin, though inferior to both of the other 
articles named, i- effective in the Bame general manner. 

Iodine, especially in the form of tincture, is useful as a local appli- 
cation in certain of the seborrheas, and as a parasiticide. It is 
often employed with mercury in the form of an ointment. The oint- 
ments compounded of the salts of iodine with mercury, though of 
unquestioned efficacy . are less employed to-day than formerly. 

Jequirity (Abrus precatorius) , employed by ophthalmologists for 
the purpose of inducing artificial inflammation of the conjunctiva, 
has been used by Shoemaker 1 in the management of lupoid and other 
ulcers. One part of the cleansed, decorticated, and bruised grains, 
macerated for twenty-four hours, and reduced by rubbing in a mortar 
to a smooth paste, was added to sufficient water to make four parts. 
This emulsion was used for local application. 

Sulphur, popularly employed chiefly as a laxative or for the local 
treatment of scabies, has also a deserved reputation in cutaneous 
therapeutics as an external agent in a wide range of non-parasitic 
1 Lancet, 1884, ii., p. 185. 



EXTERNAL TREATMENT. 119 

disorders. Hebra once regarded it as valueless in eczema, but his 
opinions on this point are not now generally accepted. It is a remedy 
of great merit in all seborrheic conditions. Precipitated sulphur is 
to be preferred to the other compounds of the pharmacopoeia. It may 
mechanically be incorporated with salve-bases, or chemically com- 
bined with vaselin and other petroleum-products, a process by which, 
as experiments have shown, its therapeutic value is not increased. It 
is also applied after mechanical union with various substances as a 
lotion. It is irritating to the acutely inflamed skin, but is much better 
tolerated than the tars in conditions of subacute or chronic exudation. 

Formaldehyd is a valuable antiseptic agent most commonly em- 
ployed as formalin, a proprietary preparation representing 40 per 
cent, of the compound. Formalin in the strength of 1 per cent, com- 
monly produces a slight irritation over the thin skin of the face ; and 
after application in the strength of 2 per cent., which should be rarely 
exceeded on the cutaneous surface, there follows a decided sensation 
of burning with a resulting transient erythema. It is a remedy of 
the highest value in the treatment of syphilodermata, acne, seborrhcea, 
the disorders produced by the vegetable parasites, several of the 
eczemas, impetigo, and other affections. It is well to color the solu- 
tion with a trace of fuchsin. 

Pyoktanin-blue is employed in aqueous saturated solution as a 
parasiticide in those disorders of the skin especially which affect 
regions beneath the clothing or which may be protected by dressings 
from exposure to the eye. It is highly valuable as a local and painless 
application in circumscribed patches of weeping or scaly eczema, in 
many of the ulcerating syphilodermata, in lupus, and in ringworm. 
It should be applied daily in several coats, each coat being permitted 
to dry before the next is superimposed. 

Potassium Permanganate belongs to the same category as pyok- 
tanin-blue, with the disadvantage that in some strengths it is produc- 
tive of pain, while the pyoktanin solution is unproductive of pain. 
From 2 to 10 per cent, solutions of the potassic salt may be painted 
on the affected surface one or more times daily till the desired effect 
is produced. The indications for its use are those which the pyok- 
tanin solution is intended to meet. 

Mercury and its compounds are of value in the local treatment of 
many disorders of the skin, syphilitic and non-syphilitic. The prepa- 
rations of mercury employed as topical agents in the treatment of 
diseases of the skin are of the highest value. They include corrosive 
sublimate, calomel, the red and yellow oxides, the biniodide and cin- 
nabar, the white and red precipitates, and the nitrate. The most 
commonly employed of their combinations are the " black wash," oint- 
ment of the nitrate, and mercurial ointment. Fumigation of the 
surface by vaporization of either cinnabar or calomel or the two in 
combination is chiefly employed in the local treatment of syphilo- 
dermata. The bichloride is most often applied as a lotion; calomel 
and white precipitate in ointments; though calomel is often effec- 



120 GENERAL THERAPEUTICS. 

tively combined with talc or starch as a powder. Startin's nitric oxid 
of mercury ointment represents a combination of two mercurials : red 
mercuric oxide, 6 grains (0.40) ; mercury bisulphate, 4 grains 
(0.25) ; simple cerate, 1 ounce (32.). Corrosive sublimate as a para- 
siticide is of great importance in the treatment of several cutaneous 
disorders due to the presence of micro-organisms, as, for example, 
lupus vulgaris. 

Chloral-camphor and Phenol-camphor have value chiefly as anti- 
pruritics. The former is obtained by rubbing together chloral hydrate 
and gum-camphor (Bulkley) until they form a clear liquid of pungent 
odor. Phenol-camphor is made by gradually adding camphor to 
melted crystals of carbolic acid, a colorless liquid resulting having the 
fragrant odor of camphor withoul thai of ihe acid. It is a useful 
local anaesthetic agent, being insoluble in water, but freely soluble in 
chloroform, ether, and alcohol. 

Many Agents arc employed upon the surface of the integumenl to 
produce in various degrees a caustic or destructive effect. Among 
these may be named the thermo-cautery ( Paquelin-knife), galvano- 
caustic apparatus, the mineral acids and alkalies, Bodium ethy- 
late, arsenic, zinc-chloride, Beveral mercurial compounds, mercuric 
nitrate, mercuric chloride, antimonious chloride, cupric sulphate, 
and argentic nitrate. Several of these substances in weak solu- 
tion are employed as milder agents for the production of irri- 
tative or even inflammatory effects. T<> 1 li. ■ latter class should be 
added iodine in tincture, chloroform, tartar emetic, croton-oil, and 
cantharides. These destructive effects are of advantage in the treat- 
ment of disorders of the integumenl due to parasites, either animal 
or vegetable. Of those employed for this purpose, and no1 mentioned 
above, may be named petroleum and Btaphysagria, for the destruction 
of lice; sulphur, Btyrax, and balsam of Peru, for the destruction of 
acari ; and sulphur and its compounds and a number of derivatives 
from tar, for the destruction of vegetable parasites. 

Counter-irritation over the Vasomotor Centres, as recommended 
by Crocker, is an efficienl mean- of relieving fixed and obstinate cuta- 
neous disorders, li may be produced by the action of sinapisms, 
blisters, or caustics over the region selected for such irritation. 

Hyperaemic Treatment — Biers. 1 — This method of treatment finds 
some application in cutaneous diseases. Both passive or venous and 
active or arterial hyperaemia may be used here as well as in other 
branches of medicine and surgery. Passive hyperemia may be in- 
duced by an elastic bandage or by means of cupping. Active hyper- 
aemia is induced by hot air. By one or the other of the methods, such 
diseases as eczema, psoriasis, sycosis, keloid, alopecia areata, lupus 
vulgaris, and staphylococcus infections may be benefited. 

A large list of medicinal substances might be added which are oc- 
casionally employed in cutaneous affections, some very rarely, the 

1 Biers ' Hyperaemic Treatment, 1908 ; Willy Meyer and Victor Schwieden. 



EXTERNAL TREATMENT. 121 

most with questionable effect. Among them may be named alcohol, 
which is of high value as a disinfectant, and hydrogen peroxide, hav- 
ing a similar effect; ether, the opium alkaloids, cocaine, belladonna, 
cannabis indica, and aconite, for anaesthetic and antipruritic effect; 
and ergot, cantharides, mustard, croton-oil, tartar emetic, benzoin, 
capsicum, rosemary, and the several salts of lead. Many of the 
articles named, such as cantharides, rosemary, and capsicum, are em- 
ployed as lotions for the scalp in the several alopecias. 

The salts of zinc (sulphate, sulphocarbolate, acetate, oxide), of 
copper, alum, lead, bismuth, and other metals are of service in dis- 
eases of the skin as productive of both astringent and stimulating or 
even of caustic effects. The careful adjustment of the dosage in each 
instance is of the highest importance, and is practically indispensable 
for the production of beneficial effects. 

Electrolysis is a method of the greatest value in the treatment of 
a large number of cutaneous affections, such as hypertrichosis, telan- 
giectases, molluscous tumors, warts, etc. It is accomplished by the 
aid of the galvanic battery in the manner described in this work in 
the pages devoted to the first of the disorders named. 

The Minor and other Surgical Operations required in the manage- 
ment of some affections of the skin are detailed in the treatises de- 
voted to that subject. Among such procedures may be named skin- 
grafting, both by the methods of Reverdin and Thiersch, and the 
several devices of plastic surgery. Strictly dermatological procedures 
to which resort must often be made are: epilation in hyphogenous 
sycosis and other affections ; massage, especially by the massering- 
ball ; the operations on the face, especially in acne, when opening small 
abscesses, removing comedones, and incising papules; and multiple 
scarification, as in telangiectases and other lesions. 

Numerous surgical and other appliances are found useful as 
adjuvants in the treatment of skin diseases. They may be employed 
to support, protect, or compress the surface, or merely to aid in the 
retention of dressings or external medicaments. Thus, the ordinary 
roller-bandage is applicable to many portions of the body ; the suspen- 
der, or suspensory bag, to the scrotum; elastic or inelastic stockings 
to the feet and legs; kid, rubber, and thread gloves to the feet and 
fingers ; and various skull-caps, face-masks, and mittens are employed 
in the case of infants and children to protect affected surfaces from 
the traumatisms of scratching. 

Apart from the surgical apparatus required for ablation of tumors 
or severe operations, a number of instruments are required for the 
daily use of the dermatologist. Among these may be named : 

A set of variously sized dermal curettes. These sharp-edged 
spoons are for erasion of the surface, and should, for general use, 
have in each a fenestrum large enough to permit the escape from the 
floor of the spoon of all collected substances. The small-sized spoons, 



122 



GENERAL THERAPEUTICS. 



however, with solid bowl and sharp edges, largely used in Vienna 
are preferable for use, especially about the face, in many skin-affec- 
tions. Epilating-foreeps, with easy springs and smooth blades meet- 
ing in perfect apposition; a set of Piffard's comedone-extractors 
provided at each extremity with a differently sized, minute, spoon- 
shaped and perforated bowl, the convex surface of which is pressed 
over the comedo with the orifice immediately over the Muck head of 
the plug. This is a great improvement over the old-fashioned comedo- 
extractor shaped like a watch-key, and the discomfort to the patient 
by its use is greatly reduced. A set of half-inch and four-inch lenses 
for examining the surface of the skin; needle-holders with light 
handles for firmly grasping the needles used in opening pustules, etc. 
Ihe needles, some of them, should be flat, with a double-cutting edge, 
others should be rounded neatly on an emery-wheel, and all of them 
carefully disinfected Too many precautions cannot be taken in the 
practice of dermatology with reaped to the disinfection of all instru- 
ments made to penetrate the skin. Probes, exploring needles, one 
dressing-forceps, delicate straight ami curved scissors, and other 
instruments from the ordinary pocke^case of the surgeon, are indis- 
pensable, ll.r instruments required for use to connection with the 
galvanic battery are enumerated to the chapter on Hypertrichosis. 

Fig. 82. 



trido platinum needle 
FW. 23. 



Milium noodle. 
Fj<;. 24. 

euttjiag iped. 

Fig. 25. 



Epilating-foreeps. 
Fig. 26. 




Piffard's grappling-foreeps. 



EXTERNAL TREATMENT. 
Fig. 27. 



123 




Piffard's cutisector. 



Fig. 28. 




Dermal curettes. 
Fig. 30. 



TIEMONAI-CO-N 

Hess's pleximeter, for observing the skin under pressure. 



FIG. 31. 



Piffard's modification of Unna's comedo-extractor. 



FIG. 32. 



O S /± OF REAL SIZE. 

Keyes's cutaneous punch. 

Fig. 33. 




Hyde's massering-ball. 

Radiotherapy 1 (Treatment by X-rays) has an established position 
as a therapeutic agent in cutaneous medicine. Among the diseases in 
the management of which it has distinct value are epithelioma, lupus 

*For complete presentation of the subject and bibliography, see: Freund, 
Grundriss der gesammten Badiotherapie, Berlin and Vienna, 1903; Williams, The 
Eontgen Kays in Medicine and Surgery, New York, 1901; Pusey-Caldwell, The 
Eontgen Eays in Therapeutics and Diagnosis, Philadelphia, 1903; Stelwagon, Jour. 
Cutan. Dis., 1903, xxi., p. 345 (with discussion before the Amer. Derm. Soc.) ; 
Pusey, Ibid., p. 355 (with discussion before the Amer. Derm. Soc.) : Bronson, 
Ibid., p. 375. For recent papers on radio-therapy see Transactions of the Sixth 
International Dermatological Congress, 1908. 



124 GENERAL THERAPEUTICS. 

vulgaris and other forms of cutaneous tuberculosis, coccogenous and 
hyphogenous sycosis, acne vulgaris, rosacea, psoriasis, hypertrichosis, 
lupus erythematosus, ringworm, and favus. The list includes diverse 
morbid conditions, but these in turn actually are remedied in many 
cases by one or the other of the therapeutic properties of the agent. 
X-rays per se are not germicidal, but indirectly, through tissue- 
reaction, they may produce such effects in a high degree, as shown by 
the partial or complete arrest of purulent discharge from the surface 
of carcinomatous or other ulcers subjected to their action. They 
produce degeneration in cells of embryonic type without destroying 
the healthy stroma in which they have developed ; cells also of higher 
differentiation are affected early. As a consequence, hair-follicles 
and sebaceous glands may become partially or wholly atrophied under 
the influence of the ray, the result depending upon its quantitative 
value. 

Clinical Effects of the rays upon normal skin vary from slight 
erythema and pigmentation to deep-seated, destructive inflammation. 
The earliest evidence manifested is either pigmentation or erythema. 
The former may be lentiginous or exhibited as a diffuse, brownish 
discoloration of differenl Bhades, the amount of pigmenl varying as a 
rule with the complexion of the patient Usually this disappears 
within a few days or weeks, though it may persisl for several months. 
Erythema appears early and Boon Bubsides, with superficial desquam- 
ation and pigmentation, it' treatmenl be suspended in time. The 
process usually lasts from a few day- to two weel<s, and is accom- 
panied by mild itching or pricking sensations. Should ilie inflam- 
matory process progress to a further stage, vesicles appear on the 
erythematous area. These maj 1"- either superficial and short-lived, 
soon drying and disappearing, or more deeply situated, and associated 
with greater swelling and increased redness, the whole area becoming 
denuded of its superficial epithelium and showing an excoriated and 
weeping surface (oj-ray dermatitis). This Burface usually becomes 
covered with a yellowish or grayish adherent pellicle, composed of 
necrotic epithelium, which gradually retracts, it- place being taken 
by normal cornified cells. In case the pellicle does not form, bluish 
islands of epithelium appear over the weeping surface, which by 
enlargement and coalescence cover the area. The new epithelium is 
smooth, delicate, bluish-white in color, devoid of pigment and hair, 
and may remain sensitive to external influences for some time. The 
duration of this degree of dermatitis is from a few weeks to - 
months, and the subjective sensations vary: usually a burning, ting- 
ling, or itching sensation is experienced, with occasionally marked 
tenderness and some pain. In a dermatitis of serious portent, the 
subcutaneous and deeper tissue is involved. The inflammation begins 
with erythema, vesiculation, and marked swelling: the skin becomes 
cyanotic and brawny, and necrosis follows. The affected area is cov- 
ered with a dry, dark-colored, leathery, adherent mass of tissue, which 
may persist for months, is surrounded by a reddish inflammatory 



EXTERNAL TREATMENT. 125 

border and is accompanied by severe pain. These lesions are chronic, 
lasting for months or years, and the cicatrix which eventually forms 
may be covered with telangiectases. Fortunately, these severe burns 
are now of rare occurrence. The majority of recorded cases occurred 
after long exposures for skiagraphic purposes. 

A chronic form of dermatitis occurs on the hands and sometimes 
on the face of #-ray operators, which is attended by scaling, atrophy, 
obliteration of the normal lines of the skin, telangiectases, alopecia, 
and at times loss of the nails. Ulcers and hyperkeratoses, some of 
which developed later into epithelioma, have occurred, and occasion- 
ally a condition simulating scleroderma has been noted. 1 

Of great importance in estimating probable results are the facts 
that the reaction of the skin exposed to the ar-rays occurs only after a 
period of delay, which may be prolonged for three weeks or more, 
and that the effects are cumulative. 

Pathological Action of a>rays has been studied both on man and in 
animals by several observers. Schlotz 2 concludes that : First, the rays 
cause a slow degeneration of the elements of the skin, in which the 
cells, not only of the epidermis and its appendages, but also those of 
the corium, may participate. This degeneration affects the nucleus as 
well as the protoplasm of the cell. The rays also induce, but to a 
much less extent, a degeneration of the fibrous elements (collagen, 
elastin), and of the muscles. Second, when the cellular degeneration 
reaches a certain point an inflammatory reaction occurs, in which 
the blood-vessels become dilated and an extravasation of serum and 
leukocytes results. The latter then seem to act as phagocytes and to 
destroy completely the degenerated cells. MacLeod 3 adds that " the 
inflammatory reaction induced by :r-rays is peculiar in that it occurs 
in a tissue the vitality of whose various elements has already been 
impaired by the action of the rays, and in that it is associated with 
greater destructive changes than those produced by actinic rays, and 
is apt to lead to ulceration and necrosis/ and is liable to be followed 
by an imperfect process of repair." An agent having such properties 
is obviously of great value, but not without danger in its application. 4 

Apparatus (X-ray). — Two forms of apparatus are in common use, 
one employing an induction-coil, the other a static machine. An 
electric current or storage batteries are essential when a coil is se- 
lected. Either apparatus will accomplish the desired end when 
properly managed. The popular idea that the static machine should 
be used for therapeutic purposes on account of its greater safety, is 
erroneous, as serious damage has been wrought by its use. A coil 
having a double or a triple winding in the primary, which may be 
connected in parallel or in series, is efficient. It should furnish a 

1 Jour. Cutan. Dis., 1903, xxi., p. 52. 

2 Archiv, 1902, lix., pp. 87 and 241 (abstr. in Brit. Jour. Derm., 1902, xix., p. 
397). 

3 Brit. Jour. Derm., 1903, xv., p. 365 (with review of literature on pathological 
action of x-rays). 

4 The treatment of #-ray dermatitis is considered with other forms of dermatitis. 



126 GENERAL THERAPEUTICS. 

spark-gap of the length of 30 cm. Four varieties of interrupters are 
used : the turbine and the dip interrupters, in both of which mercury 
is used; the Wehnelt (or electrolytic), and the vibratory interrupter; 
each of the four possesses some advantage peculiar to itself. A volt- 
meter, ammeter, and tachometer indicate, respectively, voltage, 
amperage, and frequency of interruptions. Lead plate, as a rule, is 
interposed between the tube and the skin in the vicinity of any lesion 
to be treated. The lead is placed between the tube and the patient, 
and should have an aperture of the size or slightly larger than the 
lesion to be treated through which the rays pass. Rontgen found that 
lead one-sixteenth of an inch thick was impervious to all rays. Prac- 
tically, however, one-thirty-second of an inch is sufficiently thick. 
Aluminum screens, advised by Thompson, 1 may be interposed, when 
treating deeper lesions, to intercept some of the rays which are ab- 
sorbed superficially and which induce early dermatitis. The elimi- 
nation of these rays allows the treatmenl to be pursued for a longer 
period without damage to the superficial tissues. 

Technique. — A reasonably Bafe technique was early devised by 
Schiffand Freund, a- follows: The coil should furnish a spark -gap of 
30 cm. A primary current of L2 7olt8 and U amperes is advised, 
with interruptions of 600 to L000 per minute. The tube should be 
placed 15 cm. distant from the surface treated, gradually reducing 
the distance to :> cm. The time of treatment in the beginning should 
he five, this to he increased gradually to fifteen, minutes. Three pre- 
liminary exposures <>f five minutes each, given daily, with the tube 

at a distance of L5 cm., are first to he employed. If, after an interval 

of three weeks, no unusual reaction occurs, treatmenl i- resumed and 

pursued. As there are no mean- of measuring exactly the quantity 
ot radiation from a given tube, and as the reaction in each individual 
case must be the chief guide, a perfect technique cannot he outlined. 
(For details as to duration and number of exposures, distance of the 
tube, etc., consult the chapters devoted to the diseases in which this 
treatment is recommended. ) Preliminary exposures with a view 
to testing the susceptibility of the patient should never he neglected, 
especially in the treatment of such disorders as acne and hypertri- 
chosis. The difference in susceptibility of different patients to the 
rays is not only demonstrable, but in certain cases, amounts to a dan- 
gerous idiosyncrasy. 

Tubes. — The greatest problem in radiotherapy is furnished by the 
tube. Successful treatment depends much on the ability of the opera- 
tor to recognize, to a degree at least, the condition of the tube em- 
ployed. Tubes are designated as " hard " or " soft." A hard tube is 
one in which, the vacuum being more perfect, there is a marked resist- 
ance to the passage of the electric current; its rays have pene- 
trating qualities, contain fewer of the rays absorbed superficially, 
and consequently affect the skin only after a number of exposures. 
A soft tube has the reverse effect. Its vacuum is relatively low ; it 
1 Boston Med. and Surg. Jour., 1896, exxxv., p. 610. 



EXTERNAL TREATMENT. 127 

offers but little resistance to the passage of the electric current; the 
rays produced in it are largely absorbed by the superficial tissues; 
and it readily produces dermatitis. The shadow-picture on the fluor- 
oscopic screen produced by x-rays from a hard tube shows but little 
contrast between the flesh and bones of the hand ; while with a soft 
tube the contrast, for obvious reasons, is conspicuous. A newer tube 
emits more x-rays than an older tube. Tubes become hard by use, 
and if not fitted with a regulating device, become inefficient. Rest 
softens a hard tube to some extent. The focus of the cathode rays 
need not be small for therapeutic work ; for fluoroscopy and skia- 
graphy this is essential. A tube having a regulating device of some 
sort is preferable, as it can be softened at will. 

It follows that in the treatment of superficial cutaneous diseases 
soft, or moderately soft, tubes are preferable, even though they may 
produce dermatitis if used sufficiently. It is this quality that gives 
them their efficiency. With such tubes a large amount of treatment 
is never necessary, and the reaction should be anticipated by suspend- 
ing treatment before its appearance. By careful regulation of the 
other factors, such as the intensity of the light, etc., best results may 
be obtained. In epithelioma usually a moderately hard tube is ad- 
visable, the quality depending largely on the depth of the lesion and 
the quantity of rays usually necessary for its removal. Other ele- 
ments equal, the intensity of the rays varies directly with the strength 
of the primary current (Eontgen), and the effect varies inversely as 
the square of the distance of the tube from the surface exposed. In 
epithelioma radiotherapy possesses the advantage of being a painless 
method of treatment. As pathological cells are affected and de- 
stroyed with a smaller amount of rc-rays than normal cells or normal 
connective tissue, it follows that good cosmetic results may be obtained 
when the quantity of rays applied is sufficient to destroy the diseased 
cells without injury to other structures. 

Phototherapy. — Since 1896, when Finsen published his first re- 
port on the treatment of lupus vulgaris with concentrated chemical 
rays of light, the therapeutic value of light has been studied both 
clinically and experimentally in the laboratory by many observers, 
and the literature of the subject has become extensive. 1 

The bactericidal properties of light were demonstrated first by 
Downes and Blunt in 1877, and since then by many other observers. 
The fact is now well established that the chemical rays of light, if 
concentrated and their action sufficiently prolonged, are capable of 
destroying the majority of pathogenic bacteria, though the resisting 
power of different micro-organisms differs considerably. The ex- 

*For bibliography, see Mittheilungen aus Finsen 's Lysinstitut, Nos. 1-4 (Ger- 
man translations, Leipzig and Jena, 1900-4) ; Leredde et Pautrier, Annales, 1902, 
3 s., iii., p. 341, and Phototherapie et Photobiologie (monograph of 267 pp.)> Paris, 
1903; Freund, Grundriss der Gesammten Eadiotherapie (monograph of 423 pp.), 
Berlin and Vienna, 1903; Moller, Bibliotheca medica, Abt. D 11 (monograph of 
142 pp.) ; Hyde, Montgomery and Ormsby, Jour. Amer. Med. Assoc, 1903, xl., p. 
1) ; and Montgomery, Jour. Cutan. Dis., 1903, xxi., p. 529. 



128 GENERAL THERAPEUTICS. 

periments of Finsen, Bang, Bie, Freund, Stroebel, Busch, Jansen, 
and others have demonstrated: (1) That of all parts of the spectrum 
the ultra-violet rays are the most highly bactericidal, and are also 
most stimulating to plant and animal cells, these properties gradually 
diminishing in power toward the red end of the spectrum, where 
they are comparatively slight. (2) The power to penetrate tissue 
is greatest at a certain point in the ultra-red part of the spectrum, 
and diminishes in both directions, the ultra-violet rays being absorbed 
for the most part by a thin layer of glass or by the uppermost layer 
of the epidermis, and unable to penetrate the skin more than a milli- 
meter. (3) The effective rays in the treatment of skin diseases are, 
therefore, the visible blue and violet, and the immediately adjacent 
ultra-violet rays, since these are both bactericidal and stimulating to 
cel]s and have some power of penetration. Jansen has shown that 
by prolonged action (seventy-five minutes) of the light as employed 
at the Finsen Institute in Copenhagen, bacteria may be destroyed, in 
tissue exsanguinated by pressure, at a depth of l.. r > mm., and their 
growth retarded at a depth of 4 mm. beneath the skin. The stimu- 
lating effects of the light probably penetrate somewhat deeper. 

Though the earlier studies of Widmark, Hammer, and Onna on 
the production of dermatitis and pigmentation by the violet ray-: of 
G-raber, DuBois, Bert, and Lubbock on the influence of violet rays on 
the activities of certain animals: the broader and more fundamental 
researches in this field of v. Sachs and Jacques Loeb; and the aubse- 
quenl demonstrations of Friedlander, paved the way for the later 
investigations of light-therapy, to Finsen belongs the credit of having 
first made practical and successful use of lighl in the treatment of 
disease. 

Phototherapy as employed by Finsen and his followers is based 
on the principle of concentrating a large number of chemical rays 
of light on a small area, at the same time excluding the heat rays as 
far as possible. A few seconds' expr.su re to such concent rated light 
may produce a superficial erythema, but exsanguination of the area 
to be treated and long exposures (usually one hour) are necessary to 
secure deep penetration of the light and to produce an acute inflam- 
matory reaction of the tissues. Sunlight, which Finsen employed 
at first, and which still is used to some extent by his followers, in 
summer, is too uncertain in its availability for general use, and is 
apparently less effective than a strong electric arc light. 

The light from a powerful electric arc is condensed by means 
of a series of lenses so enclosed in a metal tube as to form chambers 
which are filled with distilled water to absorb the heat rays. The 
lenses are made of rock crystal, as glass absorbs too large a proportion 
of the ultra-violet rays. The collecting lenses are 7 cm. in diameter 
(larger sizes being difficult to obtain and very expensive) and the 
rays are brought to a focus about six or seven inches from the lower 
end of the tube. Surrounding one of the divisions containing water 
is an outer jacket through which ordinary cold water circulates, thus 



EXTERNAL TREATMENT. 129 

preventing overheating of the apparatus. In Finsen's original ap- 
paratus he employed an arc light of from 60 to 80 amperes and about 
70 volts. In each quadrant of the circle around the lamp was placed 
a system of condensers, thus permitting the treatment of four patients 
with one light. This apparatus is suitable for institutions where 
numbers of patients are to be treated daily. A smaller lamp has 
been devised by Finsen and Reyn in which they use practically the 
same system of condensers, but by employing one lens of shorter 
focal distance and by so directing the arc that the strongest rays fall 
directly on the first lens, 20 amperes and 55 volts give results equal 
in every way to those obtained by the larger apparatus. The lamp 
is mounted on an adjustable stand, and is much cheaper to instal 
and maintain than the original apparatus, and more suitable for 
use outside of large institutions. 

In treating a given area, the patient should be so placed that the 
light falls perpendicularly upon the surface to be treated, which is 
brought near enough to the lamp so that the rays are concentrated in 
a circle from one-half to one inch in diameter. Throughout the 
seance this position must be accurately maintained and the area under 
treatment must be exsanguinated. The tissues are kept bloodless by 
means of constant pressure applied by an attendant with specially 
prepared compressors. These are composed of two quartz lenses 
so held together by a metal rim as to leave between them a narrow 
space through which cold water 1 constantly circulates, to prevent the 
heating of the lens. According to the contour and location of the 
area to be treated, the lens which comes in contact with the surface 
may be plane, slightly concave, or convex in varying degrees. For 
certain sites, as, for example, the inner canthus of the eye, compres- 
sors of special shape and size are made. Though in Finsen's Insti- 
tute these compressors are usually held in place by an attendant, 
who thus must give her whole time to the treatment of one patient, 
they are made so that they can be fastened in place by means of a 
tape or elastic bands. We find that by properly adjusting these 
bands and by carefully placing the patient, frequently with the aid 
of a photographer's head-rest, so that the part to be treated is well 
supported, equally good results are obtained and at much less expense 
than when each patient requires the constant attention of a nurse or 
attendant. 

The water in the compartments between the condensing lenses 
absorbs most of the heat (nearly all of the ultra-red) rays, but trans- 
mits not only the ultra-violet rays, but also nearly all of the visible 
spectrum. Consequently if the light be too concentrated the heat 
may be sufficient not only to cause pain, but also to burn the skin — 
an effect that should be avoided as it means the destruction of some 
normal tissue and the consequent production of larger and deeper 
scars. The amount of concentration which different patients and 

1 The space is so narrow that distilled water is necessary. 



130 GENERAL THERAPEUTICS. 

different conditions will tolerate varies considerably. It is desirable 
to use the rays as strong as possible without burning. 

The frequency of the applications and the duration of each vary 
for different conditions and for different individuals. For super- 
ficial lesions which can be perfectly exsanguinated, half hour ex- 
posures are often sufficient. For deep-seated lesions from one to two 
hour seances may be necessary. On each area the treatment is re- 
peated, when necessary, as soon as the reaction has subsided, which 
it does usually in from one to two weeks. 

Following each treatment an inflammatory reaction occurs in 
from six to twenty-four hours, varying in degree according to the 
intensity and duration of the treatment, from a simple erythema to 
a vesicular or bullous dermatitis which is sharply limited to the 
area to which the light was applied, though when the reaction extends 
at all below the surface there is a surrounding narrow zone of oedema. 
The outline of the area of reaction thus affords a ready test of the 
accuracy with which the compressor and light were kept in position 
during the treatment. The vesicles and bullae dry and form crusts 
which ultimately fall, leaving only the new forming epidermis. The 
process requires as a rule from eight to twelve days. The inflamma- 
tion produced by the light causes no necrosis and no destruction of 
normal tissue, all of which is conserved. Hence the inconspicuous 
scars produced and the value of the treatment from a cosmetic point 
of view. Moreover, the light may be applied freely not only to the 
morbid area, but also to the apparently normal tissue surrounding 
it, thus insuring destruction of advancing pathological processes 
which cannot be recognized clinically. Tn the normal skin, the re- 
action on subsiding is followed usually by more or less pigmentation 
which usually disappears in ten days or two weeks. Another 
effect of the light upon normal skin is to produce a slight dilatation 
of the superficial vessels which may persist for six months or more. 
The sole clinical manifestation of this condition is the readiness with 
which slight external irritation produces an erythema of the part. 

The success of the treatment depends largely upon the care with 
which the technique is carried out in all details: It is especially 
important that the lenses, both of the condenser systems and of the 
compressors, be kept absolutely clean. The latter should be cleansed 
with antiseptic solutions after each treatment. The distilled water 
in the chambers of the condensers should be changed often enough to 
keep it free from particles of dust or dirt, and air bubbles should not 
be allowed to collect on the lenses. 

Though the light treatment has been used most successfully in 
the treatment of lupus vulgaris and other forms of cutaneous tuber- 
culosis, it is of value in the treatment also of lupus erythematosus, 
alopecia areata, rosacea, vascular naevi, and some chronic inflamma- 
tory cutaneous diseases of circumscribed areas. The special tech- 
nique appropriate for each of these conditions is considered with the 
general treatment of each. Phototherapy is limited in its applica- 



EXTEENAL TEEATMENT. 131 

bility by the fact that the rajs can penetrate exsanguinated tissue 
only, and this but to a limited depth. The area treated at one time 
is small, averaging less than an inch in diameter. Consequently 
when the disorder to be treated is extensive the method as now ap- 
plied is both tedious and expensive. 

Numerous lamps have been invented in the effort to produce one 
with which more rapid results can be obtained and with less expense. 
They may roughly be divided into two classes : 

In the first class, of which the Lortet-Genoud and the London Hos- 
pital lamps are the best-known examples, the source of light can be 
brought within two inches of the region to be treated, the need of a 
condenser being thus done away with. The patient is protected from 
the light by a hollow shield in the centre of which are two rock 
crystal lenses, front and back, between which cold water constantly 
circulates and absorbs the heat rays. The part to be treated is exsan- 
guinated by pressing it firmly on the face of the front lens. An arc 
light is employed having carbon electrodes, an amperage of 10 or 12, 
and a voltage of 55. These lamps are in some respects more con- 
venient and less expensive to use than even the Finsen-Reyn lamp, 
and give good results in superficial lesions, but the light from them 
has not the penetrating power of that given by lamps which have a 
series of condensers and employ arc lights with higher amperage. 

The second class of lamps, of which there are many, are con- 
structed with the aim of furnishing ultra-violet rays in quantity. 
For this purpose iron or other metal electrodes, or the high-tension 
condenser spark, have been used. These lamps are small, convenient, 
of low amperage (1 to 4), and therefore less expensive to instal and 
to maintain. Some of them are powerful in destroying surface-cul- 
tures of bacteria and in exciting inflammation on the surface of the 
skin. As they depend for these effects upon the ultra-violet rays 
which are absorbed by the uppermost layers of the epidermis, they 
have no influence upon lesions situated at all deeply in the skin. 

Becquerel Rays. 1 — In the year 1896, Becquerel discovered the 
radiating power of uranium and some of its salts. Later the Curie's 
separated both radium and polonium from pitchblende. From rad- 
ium and its compounds there are given off at least three varieties of 
rays. One variety, apparently peculiar to these radioactive sub- 
stances, are bactericidal and have very slight power of penetrating 
tissue. The other two varieties of rays have been likened to the cath- 
ode and x-rajs respectively. Observers, however, do not agree fully 
as to the exact nature and relation of these different forms of rad- 
iation. 

The effects of radium upon tissue have not been studied suffi- 
ciently to warrant definite conclusions, but they seem to be similar 
in many respects to those of the ic-rays. Deep-seated dermatitis and 

1 For a review of the subject, and bibliography, see: Turner, Brit. Med. Jour., 
1903, ii., p. 1523: Maclntyre, Ibid., 1903, ii., p. 1524: Jumon, Jour. Mai. cutan,, 
1903, xv., p. 854, 



132 GENEBAL TEEEAPEUTICS. 

ulceration have resulted from prolonged action of the salts of radium 
on the skin. London found that in mice radium rays of sufficient 
strength produced general torpor and death. He has shown also that 
persons who are almost blind can perceive light when radium is 
brought near their eyes. It is evidently an agent that should be 
used with the greatest caution until its properties are better under- 
stood and until some method is found of accurately determining the 
exact radiating power of each preparation used for therapeutic pur- 
poses. From the results obtained in a few cases of lupus erythema- 
tosus, epithelioma, melanosarcoma, and other morbid conditions, it is 
probable that when substances possessing a definite radioactive value 
can be obtained at a reasonable price, radium and its salts may be 
utilized in the practical treatment of those superficial cutaneous 
diseases for which the rc-rays and the Finsen light are now employed. 
Liquid Air and Solidified Carbon Dioxide. 1 — These methods of 
treatment have been developed with recent years. Their action is 
essentially a caustic one induced by intense refrigeration. Liquid 
air is difficult to obtain and hence is not always available. It is kept 
in double walled glass containers which are not sealed, as evaporation 
must occur with a view to prevent explosion. It is applied to the 
skin on cotton swabs with moderate pressure. The tissue is im- 
mediately frozen white, is very hard and depressed. Within a 
short time the circulation is resumed, at which time some pain is 
experienced. Swelling, with redness and bullous formation soon 
follows. Later changes depend upon the amount of destruction 
induced. Carbon dioxide snow, suggested by Pusey, is more con- 
venient, readily obtained, and fulfills much the same requirements. 
It is only about one half as cold. It is obtained from the ordinary 
liquid carbon dioxide containers and when the snow is collected, it 
may be moulded into the required shape and applied. These agents 
are used in the treatment of naevi and benign growths, lupus erythe- 
matosus and small epitheliomata. 

'Dade, C. T., Trans. Amer. Derm. Assn. for 1905. Whitehouse, II. H., J. A. 
M. A., 1907, xlix., pp. 371-375. Trimble, W. B., J. C. D., xxx., No. 9, pp. 409-13; 
N. Y. Med. Becord, July 8, 1905. Pusev, W. A., J. A. M. A., 1907, xlix., 16, 
pp. 1354-1356. White, C. J., J. C. D., i908, xxvi., pp. 505-506. Heidingsfeld, 
M. L., Ohio Med. Journ., 1908, iv\, pp. 466-472. Zeisler, J., Dermat. Ztschr. 
Berl., 1908, xv., pp. 406-416, and J. C. D., 1909, xxvii., Jan. 



CLASSIFICATION 



The numerous attempts which have been made to classify diseases 
of the sMn according to their nature and relations have been in re- 
sponse to the generally recognized demand for a systematic arrange- 
ment of all scientific facts. As regards dermatology, not only have 
these attempts been numerous and based upon different principles, 
but the results which they have accomplished have also been in the 
highest degree divergent. No classification yet devised has secured 
general acceptance. While it is certain that no one system of classi- 
fication has been perfect, and that each has exhibited defects, it is 
equally true that of the large number each has possessed some merit 
of its own. No perfectly satisfactory classification of cutaneous dis- 
eases can be made until the knowledge of diseases of the skin has been 
greatly enlarged. 

One of the most acceptable of the systems thus far proposed is that 
of Hebra. In it cutaneous disorders are arranged in the following 
nine classes : 

Class 1. Disorders of secretion. 

Class 2. Hyperemias. 

Class 3. Exudations. 

Class 4. Hemorrhages. 

Class 5. Hypertrophies. 

Class 6. Atrophies. 

Class 7. New Growths. 

Class 8. Neuroses. 

Class 9. Parasites. 
Since this classification was devised by Hebra none has been pro- 
posed which compares in ingenuity with the arrangement made by 
Auspitz. The principle of this classification is to place together those 
diseases and groups of diseases which present a clinical unity, the gen- 
eral pathological process being the predominant characteristic for 
selection; individual characteristics, such as symptoms, localization, 
anatomical peculiarities, etc., being only brought thus predominantly 
forward when coinciding with the real nature of the class, the group, 
or the skin-disease in question. 1 Auspitz's nine classes are : 

1. Simple Inflammatory Dermatoses; 2. Angioneurotic Derma- 
toses ; 3. Neurotic Dermatoses ; 4. Stasic Dermatoses ; 5. Hemorrhagic 
Dermatoses; 6. Idioneuroses ; 1. Epidermidoses ; 8. Chorioblastoses ; 
9. Dermatomy coses. 

Under these classes, by the aid of divisions and subdivisions, an 

1 System d. Hautkrankheiten. Wien, 1881. 
133 



134 CLASSIFICATION. 

elaborate scheme is presented which embraces not only all cutaneous 
diseases, but also all pathological processes recognized in the skin. 
The mere presentation of this system has been followed by an advance 
in the nosology of cutaneous medicine more satisfactory than any 
since the contributions to this subject by Hebra. 

Auspitz's classification, however, is open to various objections on 
the part of the student of dermatology. It is elaborated to the extent 
of placing the names of some diseases in more than one family, and 
hence is confusing to the beginner. It is better adapted to the needs 
of the expert than of the student, for it introduces to the study rather 
of morbid processes in the skin than of the complexus of those proc- 
esses which are recognized in disease. 

Whether the principle of classification be anatomical, etiological, 
or pathological ; whether it be based on the processes actually occur- 
ring in the skin, or on those deeper factors and forces which operate 
centrifugally upon the skin, and on which that organ depends for all 
its functions and even its existence; whether it proceed etiologically 
from causes which are immediate or those which are remote, it is 
easy to see that, as knowledge in each of these directions enlarges, the 
exact position of any one disease in any given classification must be 
rendered insecure. Never was this observation more suggestive than 
at this day, when the pathogeny of numerous skin-disorders is re- 
vealed in the light thrown on the subject by the discovery of hitherto 
unknown organisms. 

Indeed, to this last cause, awakening grave doubts as to the pre- 
cision of much that was once esteemed fact, may be attributed the 
declining interest in the general subject of classification of diseases 
of the skin. The solution of its problems has practically been de- 
ferred by common consent to a date when the questions thus suggested 
can more satisfactorily be answered. Several recent writers have 
contented themselves with an alphabetical indexing of the names of 
skin diseases as an order useful simply for reference. 

The arrangement of titles of diseases of the skin in this treatise is 
a modification of the scheme first proposed by Hebra on the lines 
recognized by the American Dermatological Association in its classi- 
fication adopted in 1884. In the successive editions of this work 
which have appeared since this classification was first accepted, 
changes from time to time have been made which were rendered 
necessary by the advancement of science. As the arrangement stands 
to-day it should be regarded as a mode of grouping diseases for the 
convenience of the student rather than as an attempt at a scientific 
classification of diseases of the skin. 



DISEASES OF THE SKIN 



CLASS I 
HYPEREMIAS AND INFLAMMATIONS 



ERYTHEMA. 

(Gr., epvdrjfia, redness.) 



(Rose Rash. Fr., Eeytheme; Ger., Hautrothe.) 

Erythema is, strictly speaking, a mere redness of the skin due to 
congestion of the cutaneous vessels. Much confusion has arisen from 
the fact that the term is used to indicate a mere symptom, and is also 
applied to two fairly well-defined groups of cutaneous diseases. Red- 
ness of the skin, varying greatly in its intensity, duration, and distri- 
bution, is seen in many different conditions and diseases of the integu- 
ment and of the general economy. In the so-called " idiopathic 
erythemas " the redness may be the sole symptom recognizable, but it 
is usually produced by some definite internal or external form of irri- 
tation, or is symptomatic of systemic disease. Erythema may simply 
be hypersemic and be due to a congestion, active or passive, of the 
cutaneous blood-vessels, or the process may go on to exudation and 
inflammation. From a pathological point of view it is evident that 
no sharp line can be drawn between erythema hypersemicum and ery- 
thema exudativum, yet for clinical purposes it is convenient to make 
this distinction. 



ERYTHEMA HYPER^MIC'UM (seu SIMPLEX). 

Erythema simplex is a coloration of the skin in various shades of 
redness, diffuse or circumscribed, temporarily disappearing under 
pressure, the lesions differing in size, hue, and shape according to 
the extent and degree of the hyperemia by which they are induced. 

Simple erythema is seen in the phenomenon known as blushing. 
Ordinarily this is a purely physiological and transitory hyperemia 
due to emotional causes. Cases occur in which the hyperemia thus 
induced persists for hours, together with palpitation and other evi- 

135 



136 EYPEUMMIAS AND INFLAMMATIONS. 

dences of circulatory disturbance. Here the erythema is sympto- 
matic of either physical or mental disorder. With the former may 
be classed those disorders in which portions of the face remain flushed 
after eating, exercising, exposure to heat, etc. 

Under idiopathic erythema have been classed simple forms of 
erythema for which no cause is recognized. In the great majority of 
cases a careful search will disclose the disease or condition of which 
the erythema is but a symptom. The cause may be found in external 
irritation too slight and too transient to produce a dermatitis, in dis- 
turbances of the alimentary canal, in the nervous irritability of 
children due to " teething," in a drug-idiosyncrasy, or in one of many 
other derangements of the general economy. Again, the erythema 
may be a more or less important diagnostic symptom of graver consti- 
tutional disease, as in the exanthemata, typhoid fever, etc. The color 
in erythema may vary from a delicate pink or rosy shade to a dark- 
reddish hue; it may be transitory or persistent, and may be limited 
to circumscribed points, or macules, or be displayed in diffuse, ill- 
defined areas. The character, duration, and distribution of these 
rashes when due to simple causes often depend largely upon the pecu- 
liarity of the individual. The same source of disturbance or irrita- 
tion may produce different effects on the skins of different persons. 

Erythema Traumaticum. — This is the result of friction, rubbing, 
pressure, scratching, or similar external contacts. It is observed, 
for example, in the pari pressed by ihe pad of a truss; in the colored 
circle left about the leg where a tight garter has been worn; and the 
sides of the nose where pressure is exerted by eye-glasses. Trauma! ic 
hypersBinias are readily converted into exudative affections if the trau- 
matism be long continued. Intermittent pressure upon the skin 
permits restoration of the vascular equilibrium, and the integument 
responds to the demand made upon it by increasing in thickness; 
continuous pressure, on the contrary, admits of no such restoration, 
and the tissue finally becomes thinner, and yields before the agent 
inflicting the injury. Inflammation resulting in ulceration may 
finally supervene. 

Erythema Caloricum. — Extremes of heat and cold, either natural or 
artificial, are sufficient to induce transitory redness of the skin-sur- 
face. In the erythema induced by solar heat {Erythema solare) 
there is frequently also increased pigmentation of the surface, as in 
the production of freckles and " tan " in persons whose skins are 
reddened by the sun. The darker, brownish, and chocolate-colored 
stains of the hands and face thus are induced. The effects of light 
are often commingled with those of heat in cases of insolation. The 
well-known results of exposure to the Finsen lamp, where, in conse- 
quence of the cooling of the medium, no heat-rays are effective, in- 
clude erythema and even active inflammation. 

Erythema ab Igne occurs in annular and odd-looking gyrate 
patches on the anterior surfaces of the legs in cooks, firemenj and 
stokers, and in persons exposing that portion of the body to the 



EBYTHEMA BYPEBMM1CVM. 137 

direct action of heat. The annular patches may be several centi- 
metres in diameter and vary in shade from a light to a deep red or 
even a purplish tint, intense, often permanent pigmentation result- 
ing as the erythema subsides. Perry 1 believes that the phenomena 
are due chiefly to a blood-disintegration occurring in and around 
the walls of the plexus of superficial veins. He adds that the name 
Ephelis ab Igne better describes the condition. 

Erythema Venenatum. — A number of chemical substances, dyes, 
and vegetable poisons are capable of producing transient hyperemia 
of the skin. Among these may be mentioned cantharides, capsicum, 
mustard, anilin, chloroform, ether, arnica, several of the dyes used in 
commerce, and some of the essential oils. 

Erythema Gangrenosum. — Erythematous patches in some cases are 
followed by more or less extensive destruction of one or of several 
layers of the skin. T. C. Fox, in a description of the appearances 
in two cases of the affection under his observation, concludes that 
these patches are the symptoms of a feigned disease, or of one pro- 
duced artificially for the purpose of exciting sympathy, etc. The 
majority of these cases are more properly described with derma- 
titis gangrenosa. 

Erythema Lave is an obsolete term once employed to designate the 
shining redness of the skin in oedema of the lower extremities follow- 
ing any disorder sufficient to induce local tumefaction. 

Erythema Paratrimma is a term once employed for the form of deep 
and lurid redness preceding the formation of a bedsore, an accident 
which under modern methods of nursing should become as obsolete as 
the name once given it. 

Erythema Fugax is a term applied to a transitory redness of the 
skin, usually occurring in small areas, which appears and disappears 
very much as do the lesions of urticaria ; in fact, it may well be con- 
sidered a mild form of urticaria in which typical wheals are absent. 

Erythema Urticans is a fugitive form of erythema, commonly ac- 
companied by pruritic sensations, and with the production of wheal- 
like lesions. 

Symptomatic (Toxic) Erythema may be of either active or passive 
type. Numerous physiological and pathological causes operating 
upon the system at large are capable of inducing active sympto- 
matic hypersemia of the skin. These erythemas are toxic in origin. 
The redness may be generally diffused, or occur in surface-mottlings 
and markings of various sizes and shapes. Thus, the skin of the 
face may be reddened intensely in a paroxysm of rage; and that of 
the limbs of a teething child be covered with rosy maculations in con- 
sequence of the reflection to the surface, through the medium of the 
nervous system, of the irritation induced by the eruption of a tooth. 
In consequence of the rosy tint assumed by several of these rashes 
they have been termed " roseola," a name which to-day is held to 
describe a symptom rather than a disease. The word roseola is still 
1 B. J. D., 1900, p. 94. 



138 



ttYPERMMIAS AND INFLAMMATIONS. 



associated in the minds of many with the earliest syphiloderm, but 
that eruption is now best designated as the erythematous, or macular, 
syphilide. 

Roseola infantilis is sometimes described as a distinct affection in 
which there are fever and constitutional disturbance lasting a few 
hours or even a few days. The exanthem varies greatly in extent 
and distribution. It is usually macular or punctate, but may be 
finely papular; it is most common on the trunk, but may appear on 
other parts of the body; it may closely simulate scarlatina or 
measles. These phenomena are generally manifestations of some 
systemic or local disorder. 

Several of the severer constitutional maladies betray their morbid 
influence upon the central nervous system by a prompt efflorescence of 
this character. A lurid erythema of the axillary or the inguinal re- 



Fig. 34. 




Toxic erythema. 



gion may precede by several days the eruption of confluent variola. 
Cholera, cerebrospinal meningitis, diphtheria, enteric and other 
fevers, are thus at times accompanied, preceded, or followed by 



ERYTHEMA SCARLATlNIFORME. 139 

rashes. A knowledge of these rashes is of the utmost importance. 
Children who are really susceptible to the disease are often supposed 
to possess an immunity from scarlatina, as the symptomatic erythema 
previously displayed was misconstrued. Vaccination may be fol- 
lowed in from one to eight or nine days by a macular or more diffuse 
erythema of the trunk and extremities, usually accompanied by some 
febrile reaction. 

Symptomatic passive erythema is usually characterized by a cyan- 
otic, purplish, or darker hue of the integument, resulting largely 
from accumulation in excess, of carbon dioxide in the blood. The 
temperature of such skins is either normal or below the normal stan- 
dard, as in those cases in which gangrene ensues. There are many 
conditions in which these symptoms are noted, including derangement 
of the blood-vessels from imperfect innervation, direct pressure, or 
disease of the heart or vascular walls. 

These erythemas may be either circumscribed in area or general- 
ized. The term '"livedo" is applied to circumscribed regions of 
passive erythema. The nose, cheeks, fingers, or toes may be thus 
affected as in erythema pernio. The so-called " symmetrical gan- 
grene " of the fingers belongs to the same category. Cardiac cyanosis, 
or Morbus Cceruleus, is a name given to a generalized dark-blue dis-' 
coloration of the entire surface, due to continued patency of the fora- 
men ovale. 

Diagnosis. — The diagnosis of simple erythema is not difficult, 
since without exudation there is an absence of all other elementary or 
secondary lesions of the skin. The difficult point in diagnosis is to 
establish the cause. 

Treatment. — In the management of the simple forms of erythema, 
the removal of the cause is the chief object. Alkaline washes, 
boric-acid water, zinc-oxid and liquor calcis lotions, or dilute black- 
wash may be followed by the application of a dusting-powder; or the 
last may suffice. Exclusion of irritants, as in soap washing, and the 
somewhat severe domestic applications often employed in the dread 
of a serious disease, such as erysipelas, "blood-poisoning," etc., will 
often avail. 

ERYTHEMA SCARLATINIFORME.i 

(Scarlatinoid Erythema,, Desquamative So ael at iiooem 
Erythema, Scarlatinqide, Erythema Putstctatum, Roseola 

S CARL ATI JSJTFORME, " SCARLET RASH," DERMATITIS ScARLATINI- 

eormis Recidivates. Fr., Erytheme ustfectueux.) 
Erythema scarlatiniforme indicates an eruption arising from sev- 
eral causes and varying considerably in character, but having a 
tendency to simulate the rash of scarlatina. This condition has 
been described as an idiopathic disease, but so often has it been dem- 
onstrated to be a symptom only of other disorders that its existence as 
an independent affection may be doubted. 

1 For bibliography, see Dermatitis Exfoliativa. 



140 HYPEREMIAS AND INFLAMMATIONS. 

Besnier, Brocq, and other French authors describe an erytheme 
scarlatino'ide, which is acute in type, and which is always secondary 
to other infectious diseases, to auto-toxsemia, or to medicinal or food- 
toxaemia; and an erytheme scarlatini forme desquamatif, which is 
subacute in type, and which may be idiopathic, secondary to other in- 
fectious diseases, or be produced artificially by drugs. While it is 
often clinically convenient to make a distinction between acute and 
subacute forms of scarlatiniform erythema, there are no good patho- 
logical or etiological grounds for making such distinctions, since a 
given drug or given form of intoxication may produce the acute 
type in one individual and the chronic form in another. 

Symptoms. — In the acute type, which is the more common of the 
two forms, the rash may be preceded by a day or two of fever and 
other evidences of constitutional disturbance frequently lapsing with 
the occurrence of the eruption or it may appear suddenly without pre- 
monitory symptoms. The exanthem spreads rapidly and in a few 
hours, or at most in two or three days, reaches its full development. 
The eruption is commonly universal, or at least generalized, but 
may be more limited in distribution. The rash may be punctiform, 
macular, or diffuse, and the color may be any of the shades of red, 
but it is usually a bright scarlet. In some instances the appearances 
are those of a typical scarlatinal rash, except thai the eruption may 
begin on any part of the body, often sparing the face, and that desqua- 
mation begins much earlier (three or four days after the onset of the 
malady) than in scarlatina. There are usually some fever, malaise, 
and other constitutional disturbances that may vary greatly in in- 
tensity, depending upon the disease of which the exanthem is a symp- 
tom. The mucous membrane of the mouth, the tongue, and the 
fauces may be reddened or be denuded of epithelium, but the char- 
acteristic "strawberry-tongue" of scarlatina is wanting. The nails 
and hair may be shed, but only in exceptional cases. 

Desquamation usually begins in from two to six days, sometimes 
before the disappearance of the rash, and it may even occur on sur- 
faces which had not perceptibly been reddened. The scales are usu- 
ally furfuraceous, but they may be large and abundant: in rare in- 
stances the entire epidermis of the hand may be shed in glove-like 
form. Complete involution may require from a few day- to several 
weeks. Rarely the process terminates in a persistent exfoliative der- 
matitis. Recurrences are common, but in some instances may be 
prevented by the discovery of the exciting cause. 

The subacute forms of scarlatiniform erythema differ from those 
described above in that constitutional disturbances are less, the rash 
has a greater tendency to be universal, and, together with the des- 
quamation, may persist for weeks or for month's, recurrences being 
common. At times they are so frequent as to make the condition 
practically continuous and clinically indistinguishable from the milder 
forms of dermatitis exfoliativa. 

Etiology. — Idiosyncrasy is a most important factor in the etiology 



ERYTHEMA SCARLATINIFORME. 141 

of those forms of erythema which appear in certain predisposed indi- 
viduals as a result of causes totally insufficient to produce the same 
phenomena in most persons, as for example in persons exceptionally 
susceptible to quinine administered by the mouth. The exciting 
factor is usually, if not always, some form of toxaemia. Among 
many causes reported are infectious diseases, septicaemic conditions, 
toxaemias of varied origin, renal disease, peritonitis, rheumatism, 
ague in children, gonorrhoea, abscess, empyema, tuberculin-injections, 
sewer-gas poisoning (Crocker), certain articles of food, and many 
drugs. The causes are sometimes external, as when following mer- 
curial inunctions, exposure to high temperature, etc. 

Diagnosis.. — It is important to distinguish this rash from that 
of scarlet fever. Commonly the diagnosis is not difficult, as in ery- 
thema scarlatiniforme the constitutional symptoms are slight; the 
rash appears rapidly, beginning on any part of the body ; the lesions 
are exclusively cutaneous; desquamation begins early and is exten- 
sive ; the fauces though red are not swollen ; and there is absence of 
the " strawberry-tongue," of leukocytosis, and of all history of con- 
tagion. Occasionally the rash may resemble that of measles or 
rotheln, but the history of the case and the absence of other symp- 
toms peculiar to these affections should make the diagnosis clear. 
As a rule, an examination of the rash alone is insufficient, and a 
diagnosis of erythema scarlatiniforme should not be made until the 
other exanthemata have been considered and excluded. 

Treatment depends entirely on the underlying cause or condition. 
Toxines present should be eliminated as rapidly as possible. The 
rash itself rarely calls for treatment. If there be itching or burning 
sensations, a simple dusting-powder, with or without an antipruritic 
or a soothing lotion or ointment, may be used to make the patient 
more comfortable. 

Prognosis. — As a rule the eruption disappears promptly and the 
general health of the patient is unaffected. Recurrences are fre- 
quent, and in some cases terminate in a more or less persistent exfolia- 
tive dermatitis. 

Shedding of the Skin (Deciduous Skin, Keratolysis). — Cases are 
reported of individuals whose skin is shed periodically like that of a 
serpent. We had the opportunity of observing the symptoms in the 
case reported by Frank and Sanford 1 during several of the periods in 
which the patient's skin was exfoliated. The subject was thirty- 
three years of age, well formed, and apparently in perfect health. 
No cause for the skin-shedding could be found. He stated that ever 
since he could remember, and certainly since he was eight years old, 
he had had peculiar symptoms which began between 3 and 9 p. m. 
of the 24th of July, each year. He would suddenly experience 
a feeling of lassitude or weakness, followed by muscular tremors, 
nausea, and vomiting, with rapid rise in temperature. Accom- 
panying these symptoms the mucous membranes were hyperaemic; 
1 Auier, Jour. Med. Sci v Aug., 1891, 



142 HYPEREMIAS AND INFLAMMATIONS. 

the skin became hot, dry, and destitute of perspiration. After three 
or four hours the acute symptoms began to subside, but the skin 
remained red for thirty-six hours or longer. The shedding of the 
skin began usually on the second or third day, and was completed in 
from three to ten days. On the occasions observed by us, the mucous 
membrane of the tongue and mouth exfoliated on the third day; the 
epidermis was removed from the trunk and arms in large sheets on the 
sixth day ; and from the remainder of the body, except the hands and 
feet, within the next three days. Complete casts of the hands and 
feet were shed by the seventeenth clay, and the nails all came off 
within a month from the beginning of his illness. 

This case was observed the following year and reported by Sligh. 1 
Sligh's report confirms the facts we observed. Similar cases are re- 
ported by Stelwagon, 2 Stone, 3 and others. 

ERYTHEMA PERNIO. 
(Pernio, " Chilblains." Ger., Frostbeuee; Fr., Engelure.) 

Erythema pernio occurs in persons having a feeble circulation or 
of strumous diathesis, usually in the young and the very old. Permin 4 
calls attention to its frequent occurrence in ibe tuberculous. The 
redness is most conspicuous, as a rule, on the hands and feet, merely 
because of the distance of these organs from the centres of circula- 
tion. The redness is of either a light or a dusky shade ; is accom- 
panied by tenderness, itching, and burning sensations, especially 
when the part is brought near an artificial source of heat; and may 
be the origin of exudative and other affections of the skin, though the 
ulceration and sloughing which occur in extreme cases are really the 
results of freezing the organs rather than of simple exposure to cold 
when the circulation is impaired. 

Diagnosis. — The diagnosis is readily made when it is observed 
that the redness disappears on pressure, and also that the parts are 
actually cool rather than hot, the coolness being appreciable by the 
touch. J^ot rarely the involved surfaces are both cool and moistened 
with sweat. Pernio may closely resemble an early stage of lupus 
erythematosus, but the latter does not vary regularly with the seasons 
as does pernio, which usually disappears in summer and reappears 
in winter. The two conditions are at times related, as individuals 
are seen with pernio of the hands or the feet, and lupus erythema- 
tosus of the face. Cases are recorded in which the site of a recur- 
ring pernio has become the seat of a typical lupus erythematosus. 

Treatment. — The treatment of pernio should be directed to im- 
provement of the circulation and the general health. Warm clothing 

1 Sligh, Unique Case of Annual Shedding of Skin (3 plates). Internat. Med. 
Mag., 1893, p. 463. 

2 Diseases of the Skin, 5th ed., p. 143. 

3 Stone, E. M., Jour, of Am. Med. Ass., 1900, Sept, 1, p. 557 (2 cuts). 
4 Hospitalstidende, 1903, xviii., Copenhagen (abstr. in Brit. Jour. Derm., 1903, 

xv., p. 376). 



EBYTHEMA INTEBTBIGO. 143 

to protect the affected parts together with active exercise may do 
much to prevent recurrence of the disease. Fowler's solution is con- 
sidered a prophylactic if given in small doses at the beginning of 
cold weather. The local treatment is by brisk friction and stimu- 
lating lotions, such as camphorated soap-liniment ; acetous, spirituous, 
and vinous lotions; or the use of the ordinary "bay rum" of the 
shops. Afterward the parts should be painted with a 50 per cent, 
solution of ichthyol, well dusted with boric acid, and bandaged or 
wrapped in cotton. The severer forms of the disease are considered 
under Dermatitis Calorica. 

ERYTHEMA INTERTRIGO. 

(Intertrigo, Eczema Intertrigo, Chafing. 
Fr., Erytheme Intertrigo.) 

Erythema intertrigo is a hypersemic condition of those cutaneous 
and muco-cutaneous surfaces which are in constant apposition, and 
between which there is a hypersecretion or retention of sweat. 

Symptoms. — The erythema is limited to portions of the integu- 
ment which lie in contact with each other, and are subject to certain 
modifications. The sites of such contact in the human body are the 
axilla?, the groins, the cleft between the nates, the intermammary 
and inframammary spaces in women, the superior and inner faces 
of the thighs, the scroto-femoral and the labio-femoral clefts in the 
sexes respectively, the flexures of the joints, and in especially obese 
individuals all those parts where the integument is thrown into fleshy 
folds, as about the neck of infants, and even over the crest of the 
ilium in fat subjects. In these localities the disorder, beginning as 
an erythema traumaticum, proceeds by its irritative effects to stimu- 
late the secretion of sweat, which is freely poured out between 
the adjacent folds of the skin, and may there temporarily be im- 
prisoned. The surface, heated and reddened, is also somewhat mac- 
erated by the effused perspiration, and the latter, when chemically 
altered, as it is frequently under these circumstances, adds still fur- 
ther to the original disorder. The ground is thus well prepared for 
an exudative process, which not infrequently supervenes in the form 
of a dermatitis ; but the disorder may be limited to mere hyperemia 
with hyperidrosis, and disappear before the supervention of actual 
inflammation. 

The sensations produced are those of heat and tenderness. When 
the parts in contact are separated the surfaces are seen to be reddened 
and chafed. Here and there very superficial abrasions of the macer- 
ated epidermis become evident. One such abrasion is always espe- 
cially significant. It is the linear and superficial excoriation which 
marks the line of deepest contact of the two apposed surfaces of the 
skin at the bottom of the angle formed by the two. An offensive 
odor usually proceeds from the part in consequence of the chemical 
changes in the secreted fluid. The secretions of an intertrigo stain, 



144 HYPEREMIAS AND INFLAMMATIONS. 

but do not stiffen, the linen of the patient, and they thus differ from 
the serous fluid poured out in an exudative dermatitis. 

Etiology. — The disease is chiefly induced by heat, friction, and 
moisture — these causes occasionally cooperating. The heat may 
merely be that of the natural temperature of the body, or it may 
be increased by that due to season and climate. The friction also 
may merely be that originating between the surfaces in apposition, 
or it may be increased by clothing or other articles worn next the skin. 
The moisture which produces maceration of the epidermis is that 
originating in the perspiratory follicles, their secretion being doubt- 
less stimulated by the heat and friction. The interchange of oper- 
ation of these three factors, lastly, is shown by the fact that friction, 
if severe, is capable of increasing the temperature of the part to which 
it is applied. 

As aggravating causes may be named physiological secretions and 
excretions retained in contact with the surfaces affected with an inter- 
trigo. Thus, the feces of the infant left in contact with its nates 
upon the napkin; the urine of the old man with paralysis of the 
bladder or with " overflow " from prostatic disease ; the milk of 
nursing women dribbling over the breast to the inframammary region ; 
retained lochial, menstrual, and similar discharges ; and glycosuria are 
all efficient in this regard, and are particularly liable to induce that 
form of dermatitis to which the intertrigo then plays a subordinate 
part. Fleshy and gouty persons chiefly suffer from these accidents. 

Diagnosis. — The recognition of a simple erythema intertrigo is a 
matter of no difficulty if regard be had to the exciting and aggravat- 
ing causes enumerated above, and to the special localities in which 
such hyperamiia generally originates. If an eczema or a dermatitis 
supervene, the fact will appear from increased subjective sensation 
(usually severe itching), from an infiltration of the affected integu- 
ment, and from the appearance of those lesions and discharges which 
are significant of these forms of inflammation of the skin. It must 
be remembered that transition from a simple erythema to a derma- 
titis of these regions is of frequent occurrence. Erythema intertrigo 
may occur as a mild form of dermatitis seborrhoe'ica. 

The special sites of preference of intertrigo are those of the 
disease named by Hebra "eczema marginatum," or ringworm as it 
occurs upon the parts of the thighs covered by the " reinforcing " 
patch in the trousers of cavalrymen. The disease is properly named 
Tinea circinata cruris, though it is found also about the axillae, 
the buttocks, and the groins of both sexes. Here the disorder, how- 
ever, is of the exudative type, and, moreover, is distinguished by a 
characteristic " festooning " of the elevated border marking the ad- 
vancing limit of the disease. The microscope, by revealing the exist- 
ence of a fungus, will put an end to any doubt. In intertrigo the 
most marked evidence of disease is to be recognized in the deeper 
parts of the cleft between the two adjacent skin-surfaces, while in 
tinea circinata cruris the growth of the parasite is most active at 



ERYTHEMA INTEBTBIGO. 145 

the advancing border of the patch, which is, moreover, perceptibly 
elevated above the sound skin. 

Treatment. — Intertrigo is an exceedingly common affection of the 
skin, and it occasionally proves of great annoyance to those suffering 
from it. Gouty patients always require limitation of the diet, and 
often also medication with alkalies and mercurial cathartics. 

The affected surfaces should be cleansed gently by ablution with 
soap and warm water, and the offensive odor of the secretions rem- 
edied by the addition to the water of a weak solution of formalin, 
of carbolic acid, or of the dilute liquor sodse chlorinatse. The parts 
are then to be carefully dried with a freshly laundered towel or 
soft gauze, and afterward one of the dusting-powders very thoroughly 
applied. To be of service, these powders must be impalpable, and, 
if compounded by a druggist, be sifted through fine silk bolting- 
cloth. The articles chiefly used for this purpose are zinc stearate 
with acetanilid, bismuth, starch, zinc oxide, French chalk, lycopod- 
ium, or, when an antipruritic effect is desired, camphor. Combina- 
tions of several of these are at times effective. The formula of 
McCall Anderson is highly esteemed: 

Jfr Zinci oxid. pulv., 3 SS 5 16 

Camphorse pulv., 3jss; 6 

Amyli pulv., 3J; 32 

Sig. — Anderson 's dusting-powder. 

For the purpose of absorbing excessive perspiration magnesium 
carbonate is the most effective of all the powders. 

The following is the formula for a dusting-powder recommended 
by Klammann: 1 



$ Talc, venet. pulv., 3v; 20 

Acid, salieyl., gr. iij ; 

Magnes. ust. subtil, pulv., 3jss; 6 

Sig. — Dusting-powder. 



M. 



Finely bolted starch answers well alone or in combination with 
some of the other articles above named. 2 

The affected surfaces of the skin must also be separated in order 
to prevent further friction. A thin strip of lint, gauze, antiseptic 
cotton, or medicated wool may be used for this purpose, and must be 
inserted as far as the deeper portions of the cleft in which the secre- 
tion chiefly forms. Occasionally it will be found useful to anoint 
this absorbent layer with borated cold-cream salve or with vaselin. 
Where an astringent effect is desired lycopodium or other dusting- 
powder may be compounded with tannin, alum, or similar substances. 
The list of lotions also may at times be consulted with advantage. 
Thus, cologne-water, saturated aqueous solutions of pyoktanin blue, 
weak spirit lotions containing tannin, aromatic wine, or zinc oxide 
and lime-water, may each be serviceable. Lastly, equal parts of lime- 
water and olive-oil, spread thickly upon linen, will possibly give 
1 Hebam. Kalend., Obstet. Gazette, March, 1882. 

2 Unna 's salve-muslins and pastes will be found effectual and neat applications 
in many forms of intertrigo. 

10 



146 HYPEREMIAS AND INFLAMMATIONS. 

more relief than other articles named, the chief objection to it being 
the consequent soiling of the patient's clothing. 

ERYTHEMA MULTIFORME. 

(Ekythema Exudativum Multiforme. Fr., Erytheme 

PoT.YMORPHE.) 

Erythema multiforme is an acute, inflammatory, exudative dis- 
ease, characterized by crimson-red or purplish-red macules, papules, 
or tubercles, with the occasional appearance of vesicles or bullae, the 
lesions being variously grouped or isolated, and due usually to some 
systemic disturbance. 

Symptoms. — In this affection the most common lesions are oedema- 
tous-looking macules, flattened papules, and even large flat nodosities. 
Vesicles and bull re develop in some cases. While multiformity is the 
rule, one type of lesion usually predominates in each case. The 

Pro. 35. 




Erythema multiforme. 



eruption is nearly always symmetrical, and occurs usually upon 
portions of the extremities, the forearms, the legs, and the dorsum of 
the hands and feet. It occurs exceptionally on other parts of the 
body, and rarely upon the mucous membrane of the mouth, nose, and 
conjunctiva. It has been seen on the sclerotic. From the beginning 
the lesions are more or less flat, elevated, and oedematous. The 
eruption, which is generally recognized in well-defined patches, usu- 
ally begins with pinhead- to finger-nail-sized macules of a darkish-, 
bluish-, or purplish-red shade that lose their color under pressure, 
and in the course of some hours exhibit tumefaction in various de- 
grees, thus producing the papules, tubercles, and nodes already de- 
scribed. In manv cases there is a remarkable tendencv to a flatten- 



EBYTHEMA MULTIFORME. 



147 



ing and widening of the lesions to the point where they closely resem- 
ble a floridly tinted condyloma. The disease may persist for but a 
few days, but in severer grades it may last for several weeks or 
months. Recurrent attacks through a period of years are not uncom- 
mon. At the height of the exudative process there is usually an 
efflux of the coloring-matter of the blood into the skin which is the 
site of the several lesions, and thus are produced the singular shades 
of reddish black, purple and red, blue and red, yellow and orange, 

Fig. 36. 




Erythema multiforme. 



black and blue, that are characteristic of simple bruises of the ex- 
tremities when the injury has been sufficient to cause extravasation 
of blood. The lesions occur in various shapes, sizes, and shades, a 
number of names having been used to designate their several appear- 
ances that require explanation though they are without practical 
value. 

The exanthem is peculiar in that it is especially likely to develop 
and recur in the spring and autumn, is not capable of being awakened 
to activity by external irritation solely, and is productive of rather 
insignificant subjective sensations (burning and smarting) as com- 
pared with other rashes of even less brilliant hue. 

Erythema Annulare (or Circinatum) is characterized by a central 
depression and paling of color, and a peripheral extension of the ery- 
thematous patch in the form of rings which may be concentrically 
arranged. 



148 HYPEE^MIAS AND INFLAMMATIONS. 

Erythema Figuratum occurs in gyrations formed by coalescence of 
two or more annular circles. 

Erythema Induratum is considered with the tuberculous affections 
of the skin. 

Erythema Marginatum is that form of the disease in which a dis- 
tinctly elevated and defined marginal band is left as the sequel of an 
erythematous patch. 

Erythema Papulation (or Papulosum) and Erythema Tuberculatum 
(or Tuberculosum) are those forms in which occur lesions respectively 
of a papular or tubercular type, pea- to bean-sized, flattened, discrete 
or closely packed together, usually of a characteristic empurpled hue. 

Erythema Urticatum is that form in which there is severe itching, 
and, as a result, scratching of the lesions, with crusts of dark dried 
blood at the summit of each. The crust is surrounded by the light- 
red or bluish-red, flattened or elevated patch characteristic of the 
disease. 

Erythema Vesiculosum and Erythema Bullosum are exceptional forms 
in which the exudation is sufficient to raise the horny layer of the 
epidermis into larger or smaller serum-containing chambers, which 
may be, as regards the erythematous patch, of central or peripheral 
situation, and which may crown the summit of papule or tubercle. 
The fluid is usually removed by absorption, and is rarely set free by 
rupture of the vesicle or bleb. 

Bloch, 1 however, observed a fatal case of toxic erythema wheiv the 
dermatosis was erythemato-bullous in character. Vesicular lesions 
occurred on the mucous surface of the mouth, nose, and labia. Some 
of the lesions became gangrenous ; the patient died of Hodgkin's 
disease. 

Erythema Iris (Herpes Iris, Hydroa Yesiculeux) is the result of 
the evolution of successive erythematous centric lesions, which at 
times form several differently shaded concentric rings. The dorsum 
of the hand is the usual seat of this efflorescence. 

At the onset there appear one or several vesicles or vesico-papules, 
which pursue their rapid career in two or three days. Upon the 
hyperaemic ring which surrounds these lesions a second and even a 
third or fourth circlet of similar lesions form, each pushing the 
areola further to the periphery of the patch. The older lesions are 
in full retrogression, while the newer vesicles are in process of evolu- 
tion ; and the red blush which surrounds the earlier lesions is under- 
going color-changes from vivid to purple and paler hues, while the 
zone of the latest vesicles is assuming its intensest shade. The lesions 
are pinhead- to pea-sized, rather persistent and firm, and terminate 
more often by resolution than by rupture and crusting. The con- 
centric and parti-colored rings may make up a single patch an inch 
or more in diameter, or several such patches may form upon the sur- 
face of the integument. In the latter case the central disk of some 
of the patches will be seen to be composed of confluent lesions. The 
subjective sensations produced are usually trifling. 
1 Arckiv, October, 1907, lxxxvii., p. 217. 



ERYTHEMA MULTIFORME. 



149 



Atypical forms occur in which the lesions are developed imper- 
fectly from papules, and also in which, in consequence of an unusual 
exudation of serum, bullae appear. These may coalesce or be filled 
with blood ; or hematuria may result, with severe involvement of the 




Erythema multiforme. 

mucous membrane of the lips, the tongue, the soft palate, and other 
parts of the mouth, ulceration rapidly ensuing. Cases with these 
complications should really be classified with the grave forms of pem- 
phigus, to which they properly belong. 

Erythema Nodosum (Dermatitis Contusiformis. Fr., Ery th- 
eme Noueux) is a form of erythema multiforme, regarded by some 
authors as a distinct affection, in which the characteristic lesions are 
of the dimensions of semi-globular pea- to fist-sized nodes or tumors, 
pale-red, pinkish to livid blue in color, tender upon pressure, and 
exhibiting in their involution the variegations of hue already de- 
scribed. They occur chiefly upon the legs and dorsum of the feet, 
but also more rarely upon the trunk and the face. Though occasion- 
ally so soft to the touch that fluctuation may seem to be present, they 
do not terminate by suppuration. 

Unna lays stress in the distinction between this disease and ery- 
thema multiforme upon the fact that the lesions of erythema nodosum 
never widen concentrically, never produce bullae, and never exhibit 
annular vesicles, but the lesions of both types may concur in one 
individual. 

Symptoms. — The nodose lesions usually few in number and at 
times developing in crops occur most often in youth, in girls more 
often than in boys, with acute or subacute symptoms frequently with 
rheumatoid pains and febrile temperatures in various grades. The 
oval or roundish, erythematous or empurpled nodes, varying in size 
from that of a small nut to that of a pigeon's egg, are most often seen 
on the lower limbs, especially over the tibia?, though they appear also 
on the buttocks, and the forearms. Rarely the mucous surfaces of 
the mouth and throat are invaded. They are usually tender on pres- 
sure, and often painful. They may disappear in a fortnight, but 



150 EYPEEMMIAS AND INFLAMMATIONS. 

occasionally observe a stadium of six weeks' duration, forming and 
disappearing in crops. The petechial appearance of the spots where 
they have existed is that of the characteristic " black-and-blue " mark. 
The eruption may occur in tuberculous subjects and appears often 
among the poorly nourished and ill-housed. It occurs most frequently 
in the spring and autumn, and is not infrequently associated with 
arthritis or a rheumatic diathesis. Other causes cited are: malarial 
chills, temperature changes, endocarditis, urethral irritation (blen- 
norhagic, instrumental), medicamentous ingesta, alcoholic excesses, 
and dentition. 

Pathology. — The pathology of erythema nodosum is that of the 
toxic erythemata in general. Sections of lesions exhibit the common 
signs of inflammation, vascular dilatation, small-celled infiltration 
in the papillary and subpapillary layers of the corium, choking of 
lymphatic and blood-vessels, and oedema of the cells. 

The lesions of erythema nodosum should be carefully distin- 
guished from those of erythema induratum (which see) ; from the 
gummata of syphilis, which they often resemble; and from the re- 
sults of traumatism of the skin, especially of the shins. The fre- 
quently brilliant color of the erythema lesions, their failure to sup- 
purate, their association with rheumatoid and other systemic condi- 
tions, and their localization will commonly suffice to establish a 
diagnosis. 

A number of medicaments, when ingested or externally employed, 
are capable of producing eruptions identical in appearance with the 
lesions of erythema multiforme. For description of these the reader 
is referred to the sections devoted to Dermatitis Medicamentosa and 
Dermatitis Venenata. Quinine, arsenic, belladonna, chloral, salicy- 
lic acid, iodine and bromine compounds, and other substances are 
often responsible for these symptoms. 

The designation " multiform," given to this disease by Hebra, is 
justified by the singular diversity of lesions which it displays. The 
lesions are remarkable, not merely for their variety, but also for their 
occurrence in such variety both simultaneously and successively, and 
for their rapid change from one type to another. 

The subjective symptoms, save in the urticarial form of the dis- 
ease, are usually of a trifling character. The slight sense of heat 
and burning awakened by the lesions is altogether out of proportion 
to the extent of their development. 

The symptoms, however, indicative of a general disturbance of the 
system may be of a marked character. General malaise, fever, inap- 
petence, pharyngeal inflammation, chills, severe gastro-intestinal dis- 
order, rheumatoid involvement of the articulations, and even organic 
changesjn the heart (valves, endocardium, and pericardium), lungs, 
and kidneys have all been noted as coincident or as causative phe- 
nomena. In many of these cases it is clear that the exanthem be- 
longs to the list of symptomatic erythemata, and that it is of insig- 



PLATE II 




Erythema Multiforme, Cireinate Type. 



ERYTHEMA MULTIFORME. 151 

nificance in comparison with the grave general condition. It may 
thus be the precursor of typhoid fever, malaria, renal disease, severe 
articular rheumatism, or may become even an abortive expression 
of these disorders. With these exceptions, however, the prognosis 
is in general favorable, as the disease may terminate in a few days, 
and rarely exceeds a month in duration. 

Occasionally the mucous membranes are affected to a disagree- 
able or even painful extent. Thus, a sudden tumefaction of the 
uvula may supervene upon the cutaneous symptoms, in cases sufficient 
to impede respiration; or the lining membrane of the larynx may 
be involved, and the resulting aphonia in various degrees persist for 
two or three days. 

Lublinski 1 classifies the several erythemas recognized under this 
title according to Heubner's scheme: as (1) simple cases of erythema 
exudativum multiforme, and erythema nodosum, with symptoms 
varying according to the anatomical site and grade of the inflamma- 
tory process; (2) acute exanthematic forms (Erythema infectuosum) 
recognized in measles and scarlatina; (3) grave septicsemic forms, 
where the infective process often starting from the tonsils, involves 
later the cervical glands and produces a streptococcic infection of the 
system. 

Etiology. — The affection is commonest in spring and autumn; 
it occurs in the young or in the early periods of adult life ; the papular 
and tubercular forms occur more often in men, and the nodose forms 
in women; many patients are affected with rheumatism. In three 
valuable contributions to the study of the visceral complications of 
the erythema group Osier 2 has shown that the cutaneous symptoms 
may be merely surface-expressions of a visceral disorder ; and indeed 
that the skin-symptoms may wholly be absent when the disease is in 
progress. In the twenty-nine cases studied by him there were three 
sets of symptoms : (a) polymorphous skin-lesions, including acute cir- 
cumscribed oedema, urticaria, purpura, and ordinary forms of ery- 
thema multiforme; (b) visceral lesions, including (1) gastrointes- 
tinal crises in which severe colic, with or without vomiting, diarrhoea, 
or bloody stools, was frequent, (2) hsematuria and nephritis, (3) 
hemorrhages from mucous surfaces, (4) cerebral symptoms, (5) 
pulmonary complications; and (c) infiltration of synovial sheaths 
and periarticular tissues, and arthritis. In some of his cases a given 
visceral lesion had been accompanied at different times in the same 
individual by each of the types of cutaneous lesions. 

The etiology of erythema multiforme includes a list of varying 
and widely differing causes. Among the concurrent disorders may 
be named : cardiac affections, diphtheria, Bright's disease, 3 toxsemias, 
and neurotic disturbances. Severe manifestations of the disease have 

1 Angina und Erythem. Lublinski, Med. Klinik., 1906, Nr. 19; Archiv, 1907, 
83, p. 144; Centralbl., 1906, No. 11, p. 332. 

2 Amer. Jour. Med. Sci., 1895, n. s., ex., p. 629; B. J. D., July, 1900, xii., p. 
227, and Amer. Jour. Med. Sci., 1904, exxvii, p. 1, with general survey of subject. 

3 Cf. Vredensky, Vratch, 1901 (abstr. in B. J. D., 1902, xiv., p. 360). 



152 EYPEB&MIAS AND INFLAMMATIONS. 

been observed in women with extensive ulceration of the cervix uteri. 
Tilbury Fox noted frequency of symptoms in young servants brought 
to town from the country. It is not rare in young female immigrants 
who have recently made a " steerage " passage to America. Macken- 
zie 1 has called attention to the relationship of erythema multiforme 
to rheumatism and to purpura rheum atica. Polland 2 cites an obser- 
vation in which necrotic lesions of multiform erythema developed in 
a case of acute nephritis. 

Galloway 3 calls special attention to the influence of malaria as a 
cause of erythema. 

There can be little doubt that erythema multiforme, arthritic pur- 
pura, urticaria, and acute circumscribed oedema are closely related. 
The reasons for such belief, as stated by Osier, are: the similarity of 
conditions under which these disorders occur, the identity of the vis- 
ceral manifestations, and the substitution of these affections for each 
other in one and the same patient at different times. The cutaneous 
changes are undoubtedly due to the presence of toxines, which may 
not always be the same at different times even in the same individual. 
Moreover, the character of the toxine in a given case evidently is less 
effective in determining the exact nature of the cutaneous changes 
than is the individual idiosyncrasy or the temporary condition of the 
tissues. 

Pathology. — Erythema multiforme is essentially a hyperaemia of 
the integument that, under certain obscure influences, advances more 
or less rapidly to the stage of a mild grade of inflammation with 
consequent exudation. If, with Landois and Lewis, it be accepted 
that the process is the result of vasomotor nerve influence, it cannot 
be determined whether the nerves are irritated at their points of 
origin or of distribution. In the case of erythema nodosum Iiebra 
advanced the hypothesis that the morbid process is essentially an in- 
flammation of the lymphatic vessels. In some cases it is evident that 
there is extravasation of blood from the vessels into the skin of the 
affected part. 

Leloir 4 discovered in the papules, tubercles, and bullae of erythema 
multiforme only the phenomena of hyperaemia and exudation limited 
to the corium and subcutaneous tissue; and Villemin 5 simply con- 
firms these facts. Singer 6 has shown that the skin-lesions in ery- 
thema multiforme are for the most part evidences of staphylococci and 
streptococci in the blood. Crocker, examining a patch of erythema 
tuberculatum, recognized merely a cell-effusion in the upper portion 
of the corium extending sparsely below, and then chiefly along the 
ducts and follicles. There was slight rete-proliferation. tlnna recog- 

'B. J. D., 1896, viii., p. 116. 

2 Polland, E., Arcliiv, 1906, 78, pp. 247-254. 1 Clin. Illus. Bib.; Annales, 
1906, 7, p. 514; Monatshefte, 1906, 42, p. 416; Jour. mal. Cut., 1907, 25, p. 41. 

3 B. J. D., 1903, xv., p. 235 — a review of the causes of the different types of 
ervthema and of their relations to systemic conditions. 
' 4 Bull. de la Soc. anat., 1884, lix., p. 294. 

5 Gaz. hebdom., 1886, Nos. 22 and 23. 

6 Wien. klin. Wchnschrif t., 1897, p. 38. 



ERYTHEMA MULTIFORME. 153 

nizes both in erythema multiforme and erythema nodosum : vascular 
dilatation, cell-proliferation especially around the vessel-walls with 
cell-emigration, and oedema of the cutis. In two cases of the iris-type 
Pardee 1 found simply an acute exudative inflammation of the upper 
part of the corium. Torok 2 and Kreibich 3 also find the condition to 
be a simple dermatitis and not an angioneurosis. 

Diagnosis. — Erythema multiforme is always to be carefully distin- 
guished from the traumatism producing bruises, especially upon the 
lower extremities. This point may have an interesting bearing upon 
certain medico-legal questions, especially in the case of young children. 

The tendency of the disease here considered to symmetrical 
arrangement upon the two sides of the body, the recurrence of lesions 
evidently dating from several periods in which successive crops 
appear, and the absence of all history of external injury, will usually 
suffice to establish a diagnosis. Among the precocious affections of 
the subcutaneous connective tissue in syphilis, Mauriac described a 
lesion resembling somewhat the symptoms of erythema nodosum; 
but in such cases, and especially in women, mucous patches of the 
vulva, of the anus, or of the mouth, with coincident adenopathy, 
would point to the real nature of the disease. Syphilitic nodes and 
gummata are distinguished from the lesions of the nodose forms of 
erythema by the absence of pain in the former, their fewness, their 
overlying integument untinted save when actually softening and 
approaching disintegration, their obviously subcutaneous site, and the 
usual concomitant symptoms of late lues. 

The chief points by which a diagnosis of the erythemata in gen- 
eral is established are : the recognition of the vivid coloring of most 
of the lesions ; their (edematous character ; their symmetry as a rule ; 
the pigmentation following those situated on the lower limbs; their 
frequent association with rheumatism or rheumatoid pains, febrile 
phenomena, malaise, and other constitutional disturbances. The 
wheals of urticaria are smaller, more whitish centrally, more closely 
packed together, less symmetrical, rarely grouped, and, as a rule, 
decidedly more acute than those of erythema. Cases difficult to 
assign to either disease are common, and an error in either direction 
is not serious. Rubella (German measles) is to be distinguished by 
its adenopathy, its pharyngeal symptoms, and its flattish spots. In 
eczema erythematosum there is less definition of each patch, and the 
redness is commonly diffuse; papular forms of eczema are usually 
commingled with other readily distinguished symptoms of that disease. 

The relations and distinction between erythema multiforme and 
erythematous lupus are of special interest. Galloway and MacLeod 4 
call attention to the obvious relation between the two types of con- 
gestion of the skin, both due to toxines differing in virulence and 

1 Johns Hopkins Hosp. Bull., 1898, ix., p. 165. 

2 Archiv, 1900, liii., p. 243 (with review and criticism of various theories ad- 
vanced regarding the nature of the disease). 
3 Ibid., 1901, lviii., p. 125. 
*B. J. D., 1908, xx., 3, 65. 



154 HYPEREMIAS AND INFLAMMATIONS. 

character and actively affecting regions of defective peripheral circu- 
lation, the one acute and transient, the other prolonged. 

Potassium iodide and a few other drugs administered internally 
are capable of producing almost every one 01 the lesions described 
above. In the erythemata for which iodine and bromine salts have 
been administered, with the production of skin-symptoms, the con- 
fusion produced becomes a fruitful source of error. 

Treatment. — As in the majority of instances the disease under con- 
sideration progresses naturally to a favorable termination within the 
course of a few weeks, the duty of the physician is usually limited 
to the question of diagnosis and to a study of the etiology in each case, 
with the purpose of preventing future attacks. He should remember 
that the larger lesions seen in erythema nodosum never suppurate, 
and thus should not be tempted to open them surgically. Local 
treatment is often unnecessary. For the relief of the slight burning 
or itching present in some cases a dusting-powder, sedative or anti- 
pruritic lotion, or protective dressings, such as are recommended 
for the treatment of acute eczema, may be employed. Bullae and 
vesicles should be evacuated and protected with a simple aseptic 
dressing. Internally such medication should be employed as is indi- 
cated by the general condition of the patient. Iron, quinine, aspirin, 
the salicylates, salol, strychnine, and dilute hydrochloric acid will be 
found beneficial in many cases. Constipation and indigestion are to 
be corrected by appropriate measures. A full dose of calomel or blue 
mass, followed by a saline laxative, is demanded in many cases to 
aid in the elimination of intestinal toxines. When the disorder accom- 
panies rheumatic or other systemic disease, internal treatment is to be 
directed to the general condition present. When the erythema pro- 
duces extensive a?dema of the uvula, incisions may be requisite to 
prevent dyspnoea and dysphagia. 

Prognosis. — It will be gathered from what has preceded that the 
prognosis is usually favorable, but necessarily varies with the con- 
stitutional disease of which the erythema may be a mere symptom. 
The malady may relapse in susceptible individuals at those periods 
of the year when it is observed most frequently. 

The fatality in certain cases is due to the severity of the systemic 
infection as in that of Ledermann and Welonder; 1 in others, for ex- 
ample that of Polland, 2 the lesions may become necrotic and be in- 
vaded by the gangrene-bacillus. 

ERYTHEMA PERSTANS. 

(Erysipelas Perstaxs Faciei (Kaposi).) 

Erythema perstans is characterized by a brilliant scarlet or dull- 
hued, more or less persistent redness affecting the face and other parts 
of the body-surface, chiefly in children but also in adults. When 

1 Med. Klinik., 1908, No. 19; Archiv, Bd. 72, Heft 2. 
2 Archiv, Bd. 78, Feb., 1906. 



EBYTHEMA INFECTUOSUM. 155 

the face is involved, the cheeks, tip of the nose, and ears of the child 
exhibit infiltrated and often gyrate patches. The primary scarlatini- 
form aspect changes later to a bluish or bronze-like hue. In adults 
small nodular lesions may appear; and at all ages, the erythema is 
due to a fibrinous inflammatory exudate associated with intense 
vascular injection, the result of a toxaemia which may last for 
weeks and even longer. In Lenglet's three observations, the symp- 
toms resulted from renal insufficiency. Kreibich observed the disease 
as a sequel of influenza-pneumonia. In Whitfield's carefully ob- 
served case, the blood-coagulation was slow, and the infiltration speed- 
ily disappeared after exclusion of vegetable acids from the dietary, 
and administration of calcium lactate. 1 

Under the title Erythema Figuratum Perstans, Wende 2 describes 
cases observed by himself and others, in which isolated papules, 
fading centrally and extending peripherally, furnish plaques with cir- 
culate outlines often with a raised margin. Confluent, gyrate, " zig- 
zag," annular, and other forms of eruption occur, at times with 
concentric rings. In some instances the disease had existed since 
early childhood. 

ERYTHEMA INFECTUOSUM. 

(Erythema Cojsttagiosum.) 

Under these titles, Shaw- Albany, 3 describes a mild efflorescence 
occurring in children, affecting chiefly the face and extremities, the 
exanthem resembling somewhat rotheln in which maculo-papular, 
rose-tinted lesions develop at times an erysipeloid aspect. The dis- 
ease under the second of the titles given above was first described by 
Escherich, of Prague. 4 

ERYTHEME MILIAIRE LEUCOGENIQUE PRURIGINEUX 
CHRONIQUE. 

Milian 5 under this title describes pin-head-sized lesions having 
the form of elevated reddish spots with a whitish zone, the seat of 
intolerable pruritus, developing on the trunk and extremities, and 
following urticaria. The eruption seems to have resembled urticaria 
pigmentosa. 

1 Literature : Erythema annulare perstans, Bellman, Inaug. Dissert. Leipzig, 
1904; Monatshefte, 1905, Bd. 40, p. 345. 

Erythema perstans faciei, Uber die Aetiologie des; Kreibieh, Derm. Zeits., 
1908, Bd. 15, Heft 8, p. 522. 

Erytheme: La rongeur permanente de la peau dans l'insuffisance surrenale. 
Soca. La Tribune med., 19 Janvier, 1907, p. 37. Annales, 1908, 9, p. 36. 

Erythema, Persistent, Whitfield, B. J. D., 1906, 18, pp. 254-255. 

Erythema perstans faciei (Erysipelas perstans faciei, Kaposi), Kreibich, 
Monatshefte, 1906, 43, pp. 443-450. 

2 Tr. Amer. Med. Ass.; Sect. Cut. Med.; 1908, p. 75 (with plate). 

3 Amer. Jour, of the Med. Sci., Jan., 1905. 

4 Wien. klin. Woehenschr., 1904, No. 22, and Monatshefte, 1906, pp. 24-^2. 

6 Annales, 1906, 7, p. 48; Cutan., 1907, 25, p. 128. 



156 HYPEREMIAS AND INFLAMMATIONS. 



GRANULOMA ANNULARE. 

(Erythema Elevatum Diutinum, Erythema Scleroticum, Pem- 
phigoid Sclerotic Erythema, Chronic Erythema Multi- 
forme, "Ringed Eruption," Lichen Annularis, Sarcoid 
Tumors, Tumores Benigni Sarcoidei Cutis. Fr., Erythemato- 
Sclerose, Eruption Circinee Chronique du dos des Mains.) 
A somewhat rare dermatosis, chronic in course and occurring 
in both children and adults, has been described under the titles given 
above by Galloway, 1 Crocker and Williams. 2 Audry, 3 Hutchinson, 4 
E. Graham Little 5 and others. 

Symptoms. — The patients thus affected, usually children, have dis- 
played firm, solid, sharply circumscribed, elevated, pinkish, reddish, 
purplish or bluish-red nodular plaques, disposed often over the bony 
articulations of the smaller joints, especially over the hand (fingers), 
wrist, and feet, but also over the face (rarely the cheeks), elbows, 
buttocks, and lumbar region. The disease begins commonly with 
the development of whitish or reddish circular spots, which soon be- 
come elevated above the general level and increase to discrete or 
grouped papules and nodes with extension in cases to lesions two centi- 
metres in diameter. Often they have a lucent, sclerotic surface ; they 
disappear after persistence for months, with or without crusting, by 
leaving dull reddish blotches, though atrophic lesions and scars have 
occasionally resulted. In some instances a dark or violaceous zone 
surrounds the -ingle or grouped lesions. There are few if any sub- 
jective sensations. The cause is obscure. In adults rheumatism and 
gout have been thought to be efficient factors. The disease usually 
begins in the summer months. The sexes are equally affected. 

The exact relation which subsists between the conditions severally 
described as " granuloma annulare " and " erythema elevatum diuti- 
nura " is difficult to determine. The strong resemblance between the 
cases carefully indexed by Little and those described by other authors 
under the second of the two titles named, is certainly significant. In 
addition to the cases cited by Little as observed by us, we have lately 
had the opportunity of studying the symptoms in a female child five 
years of age where the nodules on the outer face of the left ankle, over 
the malleolus, were precisely similar to those represented in the photo- 
graph of our first case reproduced in Little's paper. 

Bohac, 6 describes the case of a woman 38 years of age, who suf- 
fered from recurrence of a lesion 3^ centimeters in length, developed 
on the right cheek, forming a defined elevated ring surrounded by a 

'B. J. D., 221, 1899. 

2 B. J. D., 1894. pp. 1-3 (colored plate). See also the former, 1902, 61, 
9. 219. B. J. D.. 1906. xviii., 4. p. 140. Discussion of case of child four years, 
affected in two fingers of the right hand since eighth month. 

3 Annales Jan., 1904; Bury, Illd. Med. News, May 18, 1889, p. 145. 

*IUd. Clin. Surgery, i., 1878, p. 39. 

5 Keprint, Koyal Society of Med., July, 1908. Analysis of 49 cases, 21 figures, 
and bibliography. 

6 Archiv, 1907, t. lxxxvi., p. 257. 



UBTICABIA. 157 

reddish areola which appears to be an instance of this disorder occur- 
ring in an adult. 

Pathology.. — The histological changes recognized by Audry in- 
cluded acanthosis of the rete and, deeply situated in the corium, 
disseminated lesions with perivascular inflammation. There were 
plasma cells and nuclear debris in the connective tissue, some of whose 
fibres were sclerotic; the elastin had disappeared. There were four 
times as many eosinophiles as polynuclear cells; the blood-cells were 
unchanged. 

In the analysis of Little's cases the rete at first seemed to be unim- 
paired but deeply placed in the corium and near the hypoderm, nod- 
ules were recognized where cell-infiltration affected the dilated 
sweat-coils. More closely examined, large mononuclear cells, others 
spindle-shaped or pear-shaped, and some " epithelioid " and mast-cells 
were to be seen. In other cases yet the cells seemed to be arranged 
in clumps surrounded by connective and elastic tissue, following the 
course of the vessels in long, vertical and horizontal rows. In some 
of these nodules there was central necrosis. In many of the cases 
there was a deep hypodermic inflammatory process spreading toward 
the surface. 

Treatment. — It seems clear that in the course of time many of 
these lesions disappear spontaneously. Salicylated ointments and 
pastes with or without the use of ichthyol or resorcin have proved 
efficient. Jadassohn employs arsenic internally. In many cases 
without doubt children exhibiting these symptoms require supporting 
treatment. 

URTICARIA. 

(Lat., urtica, the nettle.) 

(Hives, Nettle-rash. Fr., Ortie; Ger., Eesseesucht, 
JSTesselausschlag. ) 

Urticaria is an affection of the skin, the chief characteristic of 
which is the sudden appearance of ephemeral lesions termed wheals. 

A wheal is a sudden and ephemeral circumscribed exudation of 
fluid into the derma and subcutaneous tissue producing porcelain- 
like or rosy-tinted flat, elevated areas and accompanied by itching or 
a stinging sensation. 

Symptoms. — This disorder may be ushered in by constitutional 
symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic 
phenomena lasting for a few hours or even a day or more. 

With, and often without, such prodromic symptoms the eruption 
suddenly appears in the form of wheals upon the skin-surface, that 
frequently disappear with equal rapidity, leaving no trace of their 
existence save a slight and transitory hyperemia of the affected spot. 
The lesions may be as small as a finger-nail or a coffee-bean, and 
usually are of this size; but in rare instances " giant "-wheals are 
seen — large tomato-sized projections or flat elevations of broad areas 



158 EYPEEMMIAS AND INFLAMMATIONS. 

of the integument, that cover the greater part of the belly or buttock. 
In color the lesions are rosy-red or whitish, and are usually sur- 
rounded by a hyperaemic areola. They may be isolated and few, 
or be numerous and closely packed together; they may even coalesce, 
so that individual wheals are scarcely recognizable. They are usually 
firm and semisolid to the touch. Rarely, the homy layer of the skin 
is raised in fluid-containing lesions by the sudden effusion of serum 
beneath. Tn contour they are roundish or oval-shaped, but a variety 
of curious outlines may result from the irregularity of their develop- 
ment. Concentric circles, lines, bands, and even figures are in this 

Fig. 38. 




Dermographism. 

way produced. The finger-nail drawn across the unaffected portions 
of the skin of a patient with urticaria will often produce a linear 
wheal (" urticarial autogram ") of extent corresponding with the line 
of irritation (dermographism). In this way the so-called "med- 
ium " with a sensitive skin exhibits written characters upon the sur- 
face of his body. 

The subjective sensations induced by these lesions are distressing 
in varying degrees, according to the susceptibility of the individual. 
Every grade of pruritic burning, tickling, crawling, pricking, and 
especially stinging sensations, is thus engendered. The efforts of the 
patient to secure relief by scratching not only serve still further to 
develop the eruption, but also to irritate, tear, and otherwise wound 
the lesions already in full evolution. In this way serous effusions are 
produced at the summits of the wheals ; and in this way, also, lesions 
really transitory in their course may be changed to more persistent, 



UBTICABIA. 159 

deeply colored, flat, lenticular papules. Where the skin is delicate 
and thin, as is that of the lids and prepuce, considerable oedema may 
result. 

All parts of the body may become affected. The disease occasion- 
ally involves the mucous membrane of the mouth, pharynx, and larynx. 

The lesions numerically may be few or be so numerous as to cover 
the entire surface of the body. Though more frequently acute in 
course, they often recur from apparently insignificant causes, or even 
become chronic. In many cases apparently trivial the disease may 
become so aggravated as to make the largest demands upon the skill 
of the physician. 

The rapidity of appearance and disappearance of the lesions 
visible upon the skin is a characteristic feature of the disease. In 
some instances but a few moments are required after the operation 
of an efficient cause to develop a large number of closely packed 
wheals. Even while they are under inspection it can be noted that 
there is a change in individual lesions, some fading or completely 
disappearing, while others are newly developing. 

A number of names have been employed to designate the several 
external peculiarities of the lesions as they are presented to the eye. 
Thus, Urticaria annularis occurs in rings; IT. figurata, in gyrations 
from union of several lesions or patches of lesions ; U. vesiculosa and 
U. bullosa, where there is a vesicular or bullous development at the 
summit of the lesion; IT. papulosa (or Lichen urticatus), where there 
is a combination of the features of the wheal and the papule, the 
lesions being grape-seed- to coffee-bean-sized, and covered with blood- 
crusts where -their apices have been torn in scratching ; IT. tuberosa, 
where " giant "-wheals occur, some attaining the size of a hen's egg ; 
IT. hemorrhagica (Purpura urticata), where the urticarial element is 
developed in a lesion produced by cutaneous hemorrhage; and IT. 
evanida and perstans, where there is, respectively, a rapid or a slow 
process of involution in the characteristic symptoms. 

Baker 1 reported a case of Urticaria Tuberosa characterized by 
the presence in various parts of the body, of persistent yellowish-red 
tubercles which proceeded to ulceration. The parts most affected 
were the knuckles, the elbows, and the ear. These tubercles are said 
to have begun in a manner similar to that which characterizes the 
onset of evanescent urticarial wheals and tubercles. A somewhat 
similar case was observed by McCall Anderson. 2 

Urticaria, like erythema, may be either idiopathic or sympto- 
matic ; and in each form the urticarial conditions may underlie or be 
superimposed upon almost every elementary lesion noted in the 
integument. The wheal may complicate (or be complicated by) the 
macule, papule, tubercle, vesicle, bulla, and pustule. It may spring 
from an excoriation or may result in a fissure. It is common in 
traumatisms, and is a prominent symptom in the skin bitten by in- 
sects, reptiles, or domestic animals. 

'Lancet, August, 1881, i., p. 153. 
2 Brit. Med. Jour., 1883, i., p. 1103. 



160 HYPEREMIAS AND INFLAMMATIONS. 

Urticaria in Infants and Young Children (Fox 1 ). — The urticarial 
wheal in early life consists of a hard, pointed, pin-head-sized papule 
surrounded by a small-coin-sized areola of redness. This lesion 
may occasionally be seen in adult life. The redness may disappear 
leaving the papules, or the papule may be capped with a vesicle 
which gradually increases in size and becomes umbilicated producing 
the so-called " Varicella Prurigo." The urticarial wheal of adult 
life is less common in little children. 

Lichen-strophulus and Prurigo 2 is a form of infantile urti- 
caria occurring especially on the extensor extremities of infants and 
young children, which is frequently described as a form of prurigo. 3 
It is usually mistaken for scabies. 

The ordinary urticarial wheal, occurring in children from six to 
twelve years of age, sometimes leaves pigmentations and occasionally 
pitted scars. 

Chronic Urticaria. 4 — There are two forms of chronic urticaria: 
urticaria recidiva, in which now wheals, of the usual type, are con- 
stantly appearing during a long period of time, and urticaria per- 
stans (tuberosis cutis pruriginosa, 5 acne urtica 6 ) varieties of urti- 
caria in which pigmentations, nodules, verrucous and lichen planus- 
like lesions dominate the clinical picture. In these forms urticarial 
wheals are frequently absent when the case comes under observation, 
which renders the diagnosis a matter of great difficulty. 

Etiology. — Idiopathic urticaria always results from the action of 
external irritants, prominent among which are the bites or stings of 
mosquitoes, lice, fleas, bedbugs, gnats, wasps, caterpillars, and bees. 
The irritant action of the nettle (Urtica urens and U. dioica) has 
given the malady its name. Contact with certain species of the 
jelly-fish is also effective. The wounds thus inflicted usually give 
rise to a stinging or a burning sensation, by which the patient is 
excited to rub or scratch the part. A wheal is rapidly formed at 
the site of the injury, and the irritation set up is conveyed to other 
parts of the skin in the vicinity, so that, especially in children, a 
single traumatism by an insect may excite an urticaria covering a 
much larger area. Many medicaments operate similarly, and it 
should be added that all the external agencies which are capable of 
irritating the skin, though applied without toxic effect to the mass of 
men, may produce urticaria in individuals predisposed to the disease, 
or having a peculiar intolerance for a particular substance. Thus, 
a common flaxseed poultice when made to cover but a small portion 
of the body has produced violent symptoms of urticaria. Climatic 
influences, more particularly those in which the surface of the body 
is exposed to cold air, are efficient in the production of urticaria, as 

1 Monatshefte, 1890, vol. 10, p. 526. 

2 Henoch, Vorlesungen ueber Kinderkrankheiten, 1887, p. 829. 

3 La Pratique Dermatologique, vol. 4, p. 74. 
* Archiv, vol. 48, p. 163. 

5 Archiv, vol. 81, p. 208. 

e Ikonographia Dermatologica, Fasc. 1, Tab. II. 



UBTICABIA. 161 

also of bronchial asthma, with the symptoms of which the disease 
under consideration, in the case of adults, may often coexist or alter- 
nate. Mechanical violence, the application of leeches to the skin- 
surface, and surgical traumatisms may also act as exciting causes. 

Symptomatic urticaria is chiefly of the variety named by authors 
ah ingestis, since it most frequently results from medicinal or from 
dietary articles taken into the stomach. Of the latter class may be 
named eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery, 
crabs, lobsters, clams, caviar (and several species of fish-roe), oysters, 
and fish generally, strawberries, cucumbers, skins of grapes, nuts, 
dates, raisins, almonds, figs, prunes, gooseberries, raspberries, canned 
("tinned") fruits, meats, vegetables, oatmeal, pease, beans, onions, 
garlic, " corn," pickles, sauces, honey, mushrooms, pastry, salads, and 
spinach. Vinegar, champagne, beer, and alcoholic beverages in 
general are capable of inducing a similar effect. 

Among the medicinal articles capable of inducing urticaria may 
be named the balsams, the turpentines, quinine, glycerin, chloral, 
valerian, arsenic, hyoscyamus, cinchonidine, salicylic acid and the 
salicylates, senna, santonin, opium and its alkaloids, and the various 
vaccines including the antitoxins. 

In the case of children and infants a severe urticarial efflorescence 
may be provoked by worms, or by any undigested morsel of food, 
or indigestible material of any sort that may have been passed into 
the stomach. Thus, a bit of orange-peel or a fragment of potato- 
paring or the skins of grapes may be discovered to lie at the root 
of the trouble. In the case of adults, also, who have experienced re- 
peated attacks of urticaria, and suffer from sensitiveness of the gas- 
trointestinal tract, any food not easily digested by a given individual 
may induce in him a return of the disagreeable symptoms. 

This undue sensitiveness to the effect of ingesta or of external 
irritants is often an idiosyncrasy peculiar to the individual either on 
special occasions or at all times, and, given this susceptibility, the 
eifect is often great with a relatively insignificant etiological factor. 
Thus, a teaspoonful of beer, one grain of quinine, the smallest frag- 
ment of cheese, or but a single strawberry, may not only induce an 
urticarial rash of such extent as to cover the greater part of the sur- 
face of the body, but will also do the same on every occasion when 
the articles named are swallowed in the quantities given. The fact 
that a small quantity of the article ingested can produce urticaria is 
important, because it emphasizes the general characteristics of the 
medicamentous eruptions. The a priori reasoning, that the greater 
the quantity of the toxic agent applied or swallowed, the graver the 
effect, may lead to gross errors. It should be remembered, in seek- 
ing the explanation for an urticarial rash that the smallest amount of 
apparently innocent substances may be responsible for the largest 
annoyance. In exceptional cases the mere odors of iodoform, linseed, 
liquorice, certain plants, etc., have been sufficient to cause an attack 
of urticaria. 

11 



162 HYPEREMIAS AND INFLAMMATIONS. 

Other causes of urticaria may be cited, such as moral emotions 
(fear, shame, anger) ; pulmonary diseases, especially asthma; gastro- 
intestinal disorders, in which ingesta play no part ; intestinal para- 
sites; malaria; the exanthematous fevers, particularly in their prodro- 
mal stages; disorders of the uterus, the kidneys, and the nervous cen- 
tres; dentition, pregnancy, and the irregularities attending the 
menopause; and, lastly, the following special diseases: pemphigus, 
prurigo (of Hebra), rheumatism, and purpura. 

The close affinity of urticaria with acute circumscribed oedema, 
purpura, and erythema multiforme is discussed with the diseases 
last-named. 

Pathology. — Urticaria usually is classed as a vasomotor neurosis. 
The wheal is a sharply circumscribed oedema, and is produced appar- 
ently by an interchange of play between blood-vessels, muscles, nerves, 
and tissue, under the operation of a principle which the French term 
choc en retour. There is, first, under the influence of the vasomotor 
nerves, a clonic spasm of the arterioles in a limited area of the derma, 
by which is produced an acute oedema with serous exudate. The 
rapidity with which this clonus occurs i< greater than that with 
which the tissues of the vicinage can accommodate themselves to 
it, either by imbibition or more diffuse tumefaction, and there re- 
sults a counterpre8Sure upon the affected capillaries, by which their 
lumen is still further restricted. AlS the wheal is not a purely fluid- 
containing nor yet an entirely solid lesion, but is semifluid in con- 
sistency, the mechanical pressure is greatesl at its centre and least 
at its periphery. Thus are explained the white and relatively blood- 
less appearance of the centre of certain wlnals, and their rosy or 
reddened outer border. r riie explanation is strengthened by the fact 
that generally the most acute lesions, those springing into view most 
rapidly, are chiefly characterized by this whitened centre, while those 
more indolent or even chronic in their career, having been less Bub 
ject to the interplay of the forces described above, permit of more 
general vascular injection, and have a light-crimson or even at times 
a dull-red centre. Wheals have been excised and microscopically ex- 
amined by Neumann, Vidal, Poncet, Tuna, and others, with the re- 
sult of discovering merely evidence of dilatation and engorgement of 
blood- and lymph-vessels. The deep vascular net -hows the greatesl 
dilatation of lymph-channels. The compression of the blood-capil- 
laries produces the whiteness of the acutely developed wheal. Ac- 
cording to Poncet, the lymph-vessels are also choked with " lymph- 
clots." Eohe 1 explains the occurrence of the wheal by supposing 
that certain sensitive nerve-fibres of the skin possess also a vaso-motor 
function. 

Unna believes the wheal is produced by a spastic contraction of 
the veins. Gilchrist 2 found in the lesions of urticaria factitia of but 

1 Maryland Med. Jour., 1881, viii., p. 25. 

2 Johns Hopkins Hosp. Bull., 1896, vii., p. 140. See also Trans. VI. Int. Derm. 
Congress, 1907, pp. 905-6, 



UETICABIA. 163 

a few minutes' duration an increase in the number of round cells and 
of polymorphonuclear leucocytes, and other evidences of true inflam- 
mation. Torok 1 also finds in urticaria evidence of simple inflamma- 
tion. Torok and Hari, 2 and Phillippson 3 as a result of numerous ex- 
periments conclude that urticaria, also the oedema which is present, is 
due to the direct action of an irritant upon the vessels at the point 
where the cutaneous lesions are produced, and that the disorder is not 
therefore an angio-neurosis. Toxines may reach the vessels from 
within or from without. 

Diagnosis. — The diagnosis of classical urticaria is so readily made 
that the disease is often recognized before the attention of a physician 
is called to it. As usual, the atypical cases are those in which con- 
fusion may arise. The chief points to be remembered are : the rapid- 
ity of evolution of symptoms, their ephemeral duration, and the char- 
acteristic sensations they awaken. The action of the animal parasites 
and of insects not parasitic should not be overlooked, and the rash 
should be closely examined for the minute wounds inflicted in this 
way, often covered with a minute pin-point- to pinhead-sized dried 
"blood-scale," and usually found in groups of two, three, or more 
lesions. The various forms of erythema papulatum, tuberculatum, 
and nodosum may be mistaken for urticaria ; but this is in many cases 
inevitable, as intermediate forms between the two disorders are with 
difficulty assigned to either category. Absence of marked subjective 
sensations and persistence of lesions generally point to an ery- 
thema, while marked prevalence of these symptoms would probably 
decide in favor of urticarial disease. 

In many cases the physician is consulted by a patient who gives a 
history of well-nigh intolerable distress at night or at other capri- 
ciously selected hours, and who repeatedly and vainly endeavors to 
exhibit the lesions as they appear upon the skin. Being examined on 
various occasions, scarcely a trace of cutaneous disorder is manifest. 
Here the practitioner has actually to decide upon the character of an 
eruption he never sees ; the task is rarely difficult, no other than the 
urticarial eruption behaving in this fashion. Occasionally delicate, 
rosy or deeper stained mottlings of the skin-surface remain where 
the wheals have been. At times also on the flexor aspect of the 
forearm, or in some situation in which the skin is equally delicate, 
one or more typical lesions may be produced by the aid of a finger- 
nail in scratching, or by rubbing. These cases are frequently of the 
chronic or at least of the relapsing class, and the victims of the dis- 
ease may have a characteristic facies, a worn look from loss of sleep 
or from mental emotion. In this class often are those who mourn 
the death of relatives, the loss of property, or separation from home 
and friends, and those harassed by anxieties. 

The several lesions of erythema are larger than those of urticaria, 
and they do not develop from characteristic wheals ; in erythema mul- 

1 Archiv, 1900, liii., p. 243. 

2 Ibid., 1903, lxv., p. 21. 

3 Ibid., p. 387, 



164 BYFEFMMIAS AND INFLAMMATIONS. 

tiforme the lesions are far more persistent in type and do not provoke 
the characteristic subjective sensations of urticaria; in erysipelas the 
redness is characteristic and the swelling more diffuse. 

Treatment. — Many cases of acute urticaria demand no treatment. 
The physician is summoned for a diagnosis. The patient and his 
friends are alarmed by the dread of variola or other severe affection, 
and learning that perhaps a pickled cucumber is alone responsible for 
the disorder, they wait with equanimity for the favorable conclusion 
which is always reached. Fortunately, the unusual, severe, and 
relapsing forms rarely begin with acute symptoms. 

Naturally, the first indication to be observed is the removal of 
the cause, and with this, if possible, accomplished, the next is the ex- 
clusion of all aggravating agencies. The discovery of the cause, at 
times readily affected, is often the most serious problem presented. 
An exhaustive and minute examination of the person and the history 
of the patient, a study of his food, drink, medicine, regime, clothing, 
sleeping-apartment, habits, occupations of life, and mental state, are 
here essential. When the disorder is recent, and is an urticaria ah 
ingestis, a brisk emetic or a cathartic may rid the stomach or the 
bowels of offending matters. This done, it should be borne in mind 
that an idiosyncrasy of the patient may at this moment render the 
skin peculiarly sensitive to the action of oilier ingesta, and the diet, 
for a few days certainly, should be prescribed carefully. In many 
cases the alkalies are indicated by an acid condition of the stomach, 
and then the preparations of sodium, potassium, or magnesium are 
useful. Laxatives, such as rhubarb, magnesia, the cathartic mineral 
waters, and, in the case of children, small doses of castor-oil are fre- 
quently indicated when there is no suspicion of irritating ingesta. 
At other times there is marked atony of the digestive organs, when the 
mineral acids, the bitters, and the ferruginous tonics may be needed. 
Again, lactopeptin, pepsin, or bismuth Bubcarbonate or subnitrate may 
be exhibited with advantage for the relief of the indigestion which 
may be the prominent feature of the attack. 

Other remedies found useful in the internal treatment of urticaria 
are sulphurous acid in 1 drachm (4.) doses three times daily in sweet- 
ened water (Da Costa); copaiba; sodium nitrite (J. P. Sawyer); 
strychnine (Guibout) ; sodium arsenate, employed by Blondeau in 
doses of from V 3 o (0.002) to % (0.0013) of a grain ; the fluid extract 
of ergot in % drachm (2.) doses (Morrow) ; atropine sulphate in 
doses of Vqo (0.001) of a grain (Schwimmer) ; and sodium salicylate 
in scruple (1.33) doses. The latter drug has been praised highly 
by a number of writers. It is often given in 1 grain (0.06) doses 
every hour. Pilocarpine, or the fluid extract of jaborandi, is known 
to produce at times a powerful effect in relieving surface-congestions 
of the skin by means of the hyperidrosis it occasions ; and in propor- 
tion as the sweating is produced the drug may become dangerous. 

Schwimmer endorses the following formula for this affection: 



VET 1C AM A. 165 

I£ Atropine sulph., gr-&; 0|01 

Gum. tragacanth., q.s. | M. 

Ft. pil. No. xx. 

The treatment of symptomatic urticaria should have regard also 
to that disorder of the viscera or of the general system to which the 
cutaneous symptoms may be attributed. Gout, as a not infrequent 
cause of the disease, should not be forgotten in advising treatment. 
The woman with uterine disorder may require appropriate medica- 
tion, as also a patient affected with diabetes. Quinine is indicated, 
of course, in periodical attacks, but its action in exceptional cases 
as a direct cause of urticaria should not be overlooked; the same, to 
a greater extent, is true of arsenic, potassium bromide and iodide, 
chloral hydrate, and gelsemium. The larger number of patients are 
best treated without the employment of these drugs. 

In the local treatment of urticaria protection of the sensitive skin 
from all sources of external irritation is the chief object. The 
complete covering of an affected region with absorbent cotton will 
often cause a rapid disappearance of the symptoms. Individual 
lesions which are sealed with collodion or plaster usually disappear 
promptly. The zinc-oxide adhesive plaster is very serviceable, as it 
does not irritate the skin. The patient's underclothing should be 
of soft linen, cotton, or silk, and to prevent friction with the skin a 
dusting-powder may be used freely, both on the skin and in the meshes 
of the underwear. Sleep should be secured without an excess of bed- 
covering, and places where the temperature is for any reason elevated 
should be carefully avoided by the patient, such as proximity to a 
fireplace or a droplight, heated places of amusement, the kitchen, etc. 

Great diversity exists in the methods employed to assuage the 
disagreeable sensations experienced in the skin. This diversity is 
explained by the varying results obtained in different patients after 
the application of the same medicinal agent. Thus: cold and hot 
water-baths ; baths medicated by marine salt ; aromatic vinegar ; alco- 
hol ; cologne ; camphor ; the alkalies ; and sulphuric ether (compresses 
dipped in such solutions and laid over the part affected) ; douches ; 
and vapor baths will, any of them, in the case of some individuals, 
produce a marked alleviation of symptoms, and in others will be 
either inoperative or actually serve to aggravate the symptoms in the 
highest degree. Hebra asserts that several of the baths named above 
are useless, while Kaposi recommends cold lotions medicated with 
aromatic volatile substances. Fox prefers that alcohol, or cologne- 
water to which benzoic acid has been added, be dabbed over the part 
and permitted to evaporate. Solutions of menthol in alcohol and 
water, 1 part to 500 or 600, operate similarly. Hillairet and Gau- 
cher employ in a similar way a solution consisting of one-third of 
ether and two-thirds of warm water. 

The alkaline bath should contain sodium carbonate, sodium bibor- 



166 HTPEK^MIAS AND INFLAMMATIONS. 

ate, alum, or potassium bicarbonate, either singly or in combination 
in the strength of about 6 ounces (180.) of the salt to 30 gallons of 
water; 1 or 2 ounces (30.-60.) of potassium sulphuret may be sub- 
stituted. The Avater is made demulcent by the addition of starch or 
of gelatin, or by immersing in it a muslin bag containing bran. 
When it is desired to employ the acid bath, i ounce (15.) of either 
muriatic or nitric acid is added to the quantity of water given above. 
The bath of this size may also be medicated with 1 drachm (4.) of 
corrosive sublimate; or this drug may be used as a lotion in the 
strength of from | (0.016) to £ (0.033) grain to the pint (500.). 
( larbolic, benzoic, salicylic, boric, dilute hydrocyanic, and dilute nitric 
acids in weak solution are also employed with advantage in some 
cases. 

Other external applications are thymol, ammonium carbonate, 
potassium bromide, ether, chloroform, or chloral-camphor in the 
strength of -J to 1 drachm (2.-4.) to the ounce (30.) of ointment. 
This substance is prepared by rubbing together equal parts of cam- 
phor and chloral until a semiliquid results. The preparation i- an 
antipruritic remedy of value, but it* not largely dilutee! will increase 
the uneasy sensations produced. In other eases an oily or fatty sub- 
stance will give more prompt relief, especially if the eruption has 
been irritated by scratching and tend- to persist. Among useful 
applications may be named the liniment nm calcis of the pharmaco- 
poeia, and cold-cream salve, to which may be added fluid extract of 
grindelia robusta, 1 pari to 20 or 30 of vehicle: also the dusting- 
powders, which are described in the chapters relating to General 
Therapeutics and the Erythemata. These powders are the most 
cleanly of all external preparations in urticaria, and are often the 
only local measures required. Among the Germans, sulphur, naphtol, 
and tar-salves are employed in the management of the disease. 

One of the most effective and trustworthy of local applications in 
severe urticaria is a Btarch solution. The -lurch is first mixed with 
cold water, and is then boiled until the solution i< of the consistency 
of thin mucilage. To each pint of this 1 drachm (4.) of zinc-oxide 
and 2 drachms (8.) of glycerin are added before ebullition is com- 
pleted. When cool and applied to the surface this solution often 
gives prompt relief. The same is true of a thin solution of boiled 
oatmeal. 

Such is the empirical treatment of urticaria. It is founded upon 
no rational method of procedure, because the very capriciousness of 
the disease demands and secures relief in one instance by a treatment 
which should be reversed in another. It must be admitted that cases 
occur in which all treatment seems absolutely valueless, often really 
injurious, to the patient. These cases will usually be found to be of 
•the relapsing or chronic type. The subjects of this form of disease 
are often plunged into morbid mental states, dreading by day the 
exacerbations of the night, brooding over misfortunes experienced 
or anticipated, worn by loss of sleep, fearful of a generous regime 



UBT1CABIA PIGMENTOSA. 167 

at the table. Here the treatment is largely moral, and demands the 
tact and courage of the physician. Travel, change of climate, varia- 
tion in the routine of life, new social surroundings, and psychotherapy 
are here valuable. The widow must be made to lay aside the heavy 
crape-veil beneath which her urticaria plays ; the solitary patient must 
secure an acceptable companion for a few hours each day. 

It seems probable that to these efficient agencies must be in part 
ascribed the relief so often obtained at various mineral springs, 
both in America and abroad. Thus, the Karlsbad, Vichy, Saratoga, 
and White Sulphur Springs have all been credited with the produc- 
tion of beneficial effects in urticaria. 

Prognosis. — The prognosis of an attack of urticaria is, as may be 
seen in what has preceded, exceedingly variable in different cases. 
Simple attacks of the acute sort are trivial, and in a few days the 
patient may retain but the slightest traces of the trouble. In the 
case of children the attack is often at an end in the course of twenty- 
four hours. 

It should, however, never be forgotten that urticaria may tor- 
ment the life of a patient to the utmost bounds of tolerance and ser- 
iously impair the general health. Persistent and rebellious chronic 
urticaria may prove to be a truly formidable affection. 

URTICARIA PIGMENTOSA. 

(Xanthelasmoidea, Fox 1 .) 

Symptoms. — This disorder, once regarded as an affection of 
great rarity, has now been recognized in almost all the large centres 
of population. The disease is characterized by the occurrence in 
early infancy, sometimes but a few hours or a few weeks after birth, 
of elevated, rosy or reddish, round or oval wheals and nodules, which 
are succeeded later by flattish or slightly elevated, light or dark- 
brownish or buff-colored macules. Exceptional cases are reported 
in which the disease made its first appearance a number of years 
after birth. There are three tolerably distinct types of the affection 
those exhibiting plane lesions with equally flattened maculations 
those with tubercular, nodular, or variously sized and shaped wheals 
and mixed varieties, the latter being commonest. The mingling of a 
factitious urticaria with lesions long existing and long maculated is 
not rare. A characteristic feature of this form of urticaria is the 
tendency of the wheals to recur at the same site, and where pigmenta- 
tion remains new wheals may be produced by irritation. Cases may 
be classified into those accompanied by itching and those not thus 

1 For complete bibliography, see Blumer, Monatshefte, 1902, xxxiv., p. 213 with 
review of clinical and pathological features of the disease; and Eeiss, ibid., 1903 
xxxvii., p. 93; also Duhring's Cutaneous Medicine, vol. ii., p. 300; Wolf, Mracek's' 
Handbuch, vol. i., p. 599; Perrin, La Patique Dermatologique, vol. iv., p. 772; 
E. Graham Little, B. J. D., xxvii., p. 447, and xxxiii., pp. 16 to 38, a thorough 
exposition of the subject with an appendix incorporating the recorded English, 
German, Austrian and French cases. 



J 68 



HYPEREMIAS AND INFLAMMATIONS. 



characterized ; but these differences are due to accidental rather than 
to essential causes. The eruption, which at the outset may appear as 
late as the third year, commonly displays itself first on the neck and 
shoulders, and then rapidly spreads to the head and the extremities, 
eventually invading the entire body-surface — in well-marked cases 
even including the mucous membranes. The lesions are at first of 
the usual urticarial type, each with delicate zone, but soon lose 
their distinct contour and elevation, and become flatter and pig- 
mented, the color in pronounced cases being a distinct yellow, deep- 
ening to a decided coffee-and-milk hue. After isolated tubercles 
once acquire the deeper tint they may persist for years ; may return in 
crops ; may even at times be commingled with bullae which desiccate 

Fig. 39. 




Urticaria pigmentosa with xanthoma-like lesions. 

in crusts ; may form plaques of infiltration ; may be covered with an 
erythematous blush due to hyperemia of parts long affected; and, 
when itching is intense, may exhibit the general signs of the scratched 
skin. In a few of the reported cases the nodules were modified by 
vesicles and vesico-pustules, and were followed by whitish, instead 
of pigmented, spots in a smooth or wrinkled and scar-like skin. 



ANGlONETJBOTlC (EDEMA. i69 

Etiology. — The cause is unknown. Little 1 believes that inas- 
much as uniform blood changes were found in his cases, the disease 
is probably a congenital blood disorder of the same class as haemo- 
philia, pernicious anaemia, and lymphadenoma. 

Pathology. — Sections of tubercles have been made by numerous 
observers, including Unna, Eaymond, Pick, Thin, and Gilchrist. 
Inflammatory changes similar to those of ordinary urticaria occur, but 
in addition the papillary layer is filled with mast-cells arranged in 
columns, a feature which is characteristic of the process. Brongers- 
ma 2 and Crocker found the accumulations of mast-cells and oedema 
throughout the cutis and extending into the subcutaneous tissue. In 
apparently normal areas adjoining the lesions Gilchrist and others 
found an unusual number of mast-cells in the corium. The epidermis 
is unchanged but for an accumulation of pigment in the basal layer 
of the rete. 

Diagnosis. — Urticaria pigmentosa is to be distinguished from the 
slight pigmentation left after well-marked urticaria of later years by 
the beginning of the disease in infancy and by the persistent buff- 
colored tubercles. Xanthoma in all its forms is readily distinguished 
by its persistence in special regions, the eyelids, for example ; by its 
first appearance in many patients at a later period of life than in- 
fancy; and by its characteristic chamois-leather-yellow shade. 

Treatment. — ISTo treatment has hitherto been so successful as to 
justify its recommendation. The internal remedies and local applica- 
tions advised for urticaria have been employed with varying degrees 
of success. The best results are obtained after stimulating rather 
than soothing baths, at a later period of life than during the first six 
months. After such stimulation with salt and water or alcohol and 
water a boric-acid dusting-powder may be employed. 

ANGIONEUROTIC OZDEMA. 

(Giant Urticaria.) 

This form of urticaria was first described by Bannister. 3 It is 
simply a special variety of urticaria, In ordinary urticaria it is not 
uncommon to observe a few giant-wheals, egg-sized and larger. In 
some cases where the patient has successive attacks the wheals may 
be of the giant variety in one attack; again, the patient may have 
successive attacks and exhibit only giant wheals. 

Symptoms. — Giant-wheals are usually not very numerous and fre- 
quently they are single, sudden, ephemeral, egg- to fist-sized cir- 
cumscribed oedematous swellings, affecting any part of the integument 
but exhibiting an especial predilection for the lips, eyelids, and 
scrotum. In some cases the patients complain of general pruritus 
accompanying the lesions. The tongue may be greatly swollen; 

1 B. J. D., 1906, p. 16. 

2 B. J. D., 1899, xl, p. 179 (with review of pathology). 

3 Chicago Medical Beview, June 20, 1880. 



170 SYPEUMM1AS AND INFLAMMATIONS. 

acute swelling of the pharynx may be mistaken for an abscess. 
Alarming dyspnoea may result where the oedema affects the larynx. 
Transitory stricture of the oesophagus has occurred. This form of 
acute circumscribed oedema may affect the brain in the diagnosis of 
which a history of repeated attacks of urticaria is important. 

Circumscribed and Persistent (Edema of a single member or 
region of the body, not of the class of successive and repeated swell- 
ings noted above, is properly considered with the early stages of ele- 
phantiasis. It results most often from a localized lymphangitis or 
from so-called "recurrent erysipelas" (chronic eczema of the face, 
tumefaction of nose and cheeks due to obstruction by tumors of the 
antrum of Highmore), and appears upon the face usually as a smooth, 
shining, whitish or reddish tumefaction, ill defined as a rule, in a few 
cases with fairly good definition. The tuberculous toxines may be re- 
sponsible for some cases. The swelling is usually of firm consistence, 
but can with some pressure be indented with the finger. Tt is always 
the seat of passive hyperaemia, never of active inflammation; but in 
the case of smokers of tobacco and hard drinkers an active inflamma- 
tion is sometimes awakened. These patches are rarely painful or ten- 
der; advice is usually sought with a view to the relief of the conse- 
quent moderate deformity. The swellings occur as well upon the 
Lower limbs and breasts of women. (Cf. Erysipelas perstans.) 

Treatment. — Treatment is by frequent shampooing- ;ih<1 embroca- 
tions, to stimulate the absorbents, aided by elastic compression. 
Facial deformities of this class are benefited by abstention from the 
use of tobacco and alcoholic stimulants, the diet at the same time 
being carefully regulated. The aasa] cavity, the region of the orbit, 
and the mouth (caries of the teeth, etc.) should always be examined 
with a view to the removal of the cause. 

PRURIGO. 

(Lat., prurire, to itch.) 

Prurigo of Hebra, Prurigo Gravis. Prurigo Ferox, Prurigo 
Agria. Prurigo Mitis. 

Prurigo is a chronic, exudative, cutaneous affection, commonly 
beginning in infancy or early childhood, continuing through life, and 
characterized at first by urticarial symptoms, later by the occurrence 
on the extensor surfaces of the extremities and also on the trunk, of 
minute, pale or reddish papules, accompanied with an intolerable 
pruritus. 

Prurigo is one of those terms which in the past have led to con- 
siderable confusion in the nomenclature of cutaneous disease. In 
England chiefly it is applied with more or less looseness to disorders 
accompanied by the subjective sensation of itching, such as the 
prurigo mitis of Willan, and the disease well recognized under the 
title " pruritus." 



PnPBlGO. 171 

The title " prurigo " in this connection is strictly limited to the 
disease to which the name was originally given by Hebra, a disorder 
beginning in earliest life and continuing throughout its duration. 
Once observed only or chiefly in Austria, it has now, in consequence of 
extensive immigration, been seen occasionally in America. 

Symptoms.; — The earliest symptoms are usually displayed in the 
latter portion of the first year of life, in the form of an urticarial 
rash, which persists and which is finally succeeded by typical pap- 
ules of the disease. These papules are millet-seed- to hemp-seed- 
si?ed, in color not differing markedly from that of the normal skin. 
They are intensely pruritic, and rapidly become covered with blood- 
stained crusts in consequence of the induced scratching. As a result 
of this trauma there ensues a long train of complications, including 
pustulation, fissures, excoriations, dense infiltrations, crust-formation 
from exuded serum and dried blood, cedema, lichenification, and 
diffuse dark-brown pigmentation of the skin-surface in large areas. 
The glands which receive the lymphatic flow from the excoriated 
areas are enlarged. This adenopathy is conspicuously shown in the 
inguinal and cubital glands. Fully developed, the disease presents 
in general the same physiognomy in patients of different ages. The 
extremities always exhibit the severest manifestations of the disease, 
and of these the leg and forearm are usually affected more severely 
than the thigh and arm ; though the trunk, the forehead, the neck, 
the face, and the scalp may also be involved. The extensor sur- 
faces are invariably selected by the disease, while the flexor sur- 
faces, such as the axillae and the groins, except as regards adenopathy 
are free from change. The general health of the patient manifestly 
suffers from the insomnia and nervous agitation induced by the state 
of the integument. Emaciation, malnutrition, and cachexia are 
common sequels. The mental and moral tone of the patient thus 
harassed from early childhood throughout an entire life is necessarily 
profoundly impaired. Insanity and suicide are reckoned among its 
remote consequences. 

Mild and severe forms of the disease are distinguished under the 
terms Prurigo mitis, Prurigo ferox, or agria; they agree with 
respect to the evolution of symptoms; the only difference to be ob- 
served is in their intensity. In the former the papules are fewer, the 
recrudescence rarer, the itching less intense, and the amenability to 
treatment more pronounced. "While incessant and judicious treat- 
ment, climatic influences, and comfortable conditions of life are fac- 
tors which mitigate the symptoms, the difference between the two 
forms is probably largely determined by the intensity of the causal 
elements which first establish the disease in the individual. A pru- 
rigo which begins with severe symptoms may persist in the ferox form 
throughout life : while a prurigo mitis is such from the first appear- 
ance of the disorder. 

Etiology. — The disease occurs chiefly in Austria, few cases being 
recorded elsewhere. Wigglesworth, Campbell, Zeisler, and others 



172 HYPEREMIAS AND INFLAMMATIONS. 

have reported cases in America. The actual cause of prurigo is not 
positively known. It is encountered more often in the male sex, is 
never contagious, and is never induced by lice; but, according to 
Hebra and Kaposi, it may be grafted upon an hereditary predis- 
position ; several cases have been known to appear in one family, sug- 
gesting strongly an hereditary element. " Scrofula," tuberculosis, 
malnutrition, " misery," poverty, anaemia, and filth are held to be 
severally favorable to its development. The disease is practically lim- 
ited to the poorer classes living under wretched hygienic and social 
conditions. Some authorities, especially among the French, hold that 
the disease has a neurotic base ; that the pruritus is the essential 
element, the papules developing from the irritation of scratching. 
Others believe that a toxic cause operates, because of the urticaria at 
the beginning and the frequency of stomach and bowel disturbances 
in those who are afflicted. Tt is highly probable that both theories 
have a more or less true relation to the etiology of the disease. 1 

While typical prurigo ferox, as described by the Vienna school of 
authors, is of such rarity thai probably less than a dozen cases have 
been reported in America, the opinion is gaining ground that the 
same disease with milder manifestations (prurigo mitis) is much 
more common here than has been believed. Patients with severe 
prurigo, treated by Hebra himself, have found their way to our clinic; 
they bore unmistakable symptoms of improvement after a residence 
in the United States. Almost every American expert has observed 
cases of milder type. 

Pathology.- Kaposi practically admits that, striking as is the 
clinical portrait of tin's disease, its anatomical features are indis- 
tinguishable from severe forms of obstinate papular eczema, or from 
other forms of chronic dermatitis accompanied by hyperplasia. The 
microscope reveals proliferation and swelling of rete-cells, cell-infil- 
tration and oedema of the papillae, most marked around the vessels, 
and frequently dilated lymph-spaces. There is a scattered deposit of 
pigment in the corium, and many cutaneous muscles (erectores 
pilorum) are thickened and shortened. Holder 2 states that these 
muscles are not only hypertrophied but also are contracted, and that 
the papule has an urticarial basis. 

Some authors contend that the papules are solely due to trau- 
matism of the pruritic skin. Auspitz believes that the disease is in 
fact a sensori-motor neurosis without essential lesion. Riehl 3 con- 
siders it as a chronic form of urticaria. Leloir and others find the 
prurigo-papule invariably resulting from a cystic degeneration of 
rete-cells, thus forming a cavity which at first contains clear serum 
with the addition later of epithelial debris. The walls of the cyst 
later undergo keratinization. 

Bernhardt, 4 after studying a typical case in a patient with a para- 

1 Cf. Matzenauer. MraCek's Handbuch, Bd. ii., pp. 701-714 (with bibliography). 

2 J. C. D., 1901, xix., p. 489. 

3 Vierteljahr., 1884, xl., p. 41. 

♦Archiv, 1901, lvii., p. 175 (bibliography). 



PBUBIGO. 173 

lyzed arm, believes the disease is a dystrophy of the corium due to 
chronic irritation of the trophic centres, and that the papule precedes 
the pruritus. 

White, 1 in a review of the subjects which sets forth the great 
diversity of opini.on as to the nature and cause of prurigo, concludes : 
" I cannot go farther than accept the existence of a condition of early 
childhood, allied to pruritus and urticaria in its visible manifesta- 
tions, and not to be distinguished positively from them in its first 
stages, often becoming in certain parts of the world a chronic affec- 
tion due to some inexplicable national cutaneous traits, or inherent 
customs of living; a condition which certainly lacks many of the 
essential elements of individuality." 

Diagnosis. — Remembering the extreme rarity of prurigo in Amer- 
ica it is to be distinguished chiefly from the various forms of papular 
eczema by the location of its lesions, by the course of the disease, by 
the age of the patient when it is first developed, by the great extent 
of the eruption, and by the uniform type of its lesions. In prurigo, 
also, the fingers and the toes, the flexor aspects of the extremities, 
and the face are more or less spared. Under treatment eczema com- 
monly yields at least in some portions of the skin, while prurigo does 
not. 

From pruritus, prurigo is readily diagnosticated by its general 
physiognomy and history, by its peculiar pigmentations and infiltra- 
tions, and by the special region chiefly affected. But both diseases 
may complicate prurigo, especially eczema, which is then ordinarily of 
artificial origin. In pediculosis corporis the parasites usually will 
be found upon the underclothing, while the lesions induced by the 
finger-nails never form closely packed papules. There is something 
highly characteristic in the widely separated excoriations, the puncta 
from wounds inflicted by parasites, and the inflamed papules seen 
upon louse-bitten patients. 

In scabies the characteristic burrows of the parasites will usually 
be recognized, as also vesicular and pustular lesions. Urticaria can be 
mistaken for prurigo only in the earlier stage of the last-named disease. 

Treatment. — In Vienna, sulphur, naphtol, tar, green soap, baths, 
and frequent anointings with oily and fatty substances have occasion- 
ally served to ameliorate the severe symptoms of the disease. Mer- 
cury, ichthyol, salicylic acid, carbolic acid, boric acid, and diachy- 
lon and zinc ointments may also be employed upon different portions 
of the skin when indicated. 

The Wilkinson salve, representing a combination of tar, sulphur, 
and green soap, has proved of special value in many cases. Vle- 
minckx's solution (q. v.), followed by hot bathing, and corrosive- 
sublimate baths, 1 drachm (4.) of the sublimate to 30 gallons of 
water, have also been recommended. Fox 2 reports a case relieved with 
sulphur and ichthyol ointments. Internally arsenic has proved value- 
less, while carbolic acid occasionally has seemed beneficial. Cod-liver 

l J. C. D., 1897, xv., p. 2 (with bibliography). 
2 J, C. D., 1903, xxi., 148-229. 



174 HYPEREMIAS AND INFLAMMATIONS. 

oil and the ferruginous tonics with the bitters are indicated in many 
patients suffering from malnutrition. A generous diet and a tonic 
regimen are often essential to the management of the disease. It is 
to be noted of all cases that they are influenced happily by the warm 
weather of the summer season and by special attention to cleanliness 
and hygiene. 

Prognosis.- — The disease usually persists through life. The most 
favorable conditions are those in which the patient is young and sur- 
rounded by circumstances which permit of provision for his needs. 

PRURIGO NODULARIS. 1 

(Multiple Tumors of the Ski?* Accompanied by Intense Pru- 
ritus — TIardaway ; Multiple Tumors or the Skin Asso- 
ciated With Prurttur — Schamberg and Hirsciiler). 
In the year 1880, Hardaway, of St. Louis, described this rare 
disease in a female patient under his care, a biopsical examination 
having been made by Eleitzmann. In L906, Schamberg and Hirscii- 
ler described two cases of a similar character occurring in negroes. 
Tn duly, 190S, the wife of a physician in a distanl state was senl to 
me presenting the same features as those observed by the authors 
named above. These four cases seem to represent the only observa- 
tions made respecting tins rare and singular disorder. 2 The follow- 
ing description includes the chief features of the four cases: 

Symptoms. — The patients were women, aged respectively 25, 40, 
42, and .">l years; three married, the married patients hud all been 
pregnant; all were fairly well nourished; two were in comfortable 
social circumstances; two were negresses. 

The eruptive symptoms were firm, pea- to finger-nail-sized 
nodules occurring in greal numbers on the back but chiefly over 
the extremities (hands, arms, feet — a few oxer the soles legs, 
and thighs). The smaller were at first covered with a smooth envelope 
whitish, pinkish, or brownish (blackish on the negro-skin); as they 
grew older, they became rough, acquired a horny consistency, and 
often developed at the summit a suggestion of a verrucoid process. 
After scratching which was practiced in all eases, the surface of the 
nodules became furrowed, fissured, and at times hemorrhagic. In 
some instances the nodules became fused in a plaque of infiltration; 

'Bibliography: Hardaway. N. Y. Journ. of Derm., 1880, April; Trans. Am. 
Derm. Association, 1879, p. 78. Schamberg ami Hirsciiler, J. C. D., 1906, April, 
xxiv., 151 (plate and four figures). 

: Since these paragraphs were written. Dr. Jackson presented to the New York 
Dermatological Society, a woman, twenty-one years of age, who had been for ten 
years the subject of a disorder described as "multiple tumors associated with 
itching." This may have been an instance of prurigo nodularis. In the discus- 
sion, Dr. Johnston stated that the general appearance, behavior, and histological 
characters of the disorder justified its assignment to the prurigo group. (J C D. 
1909, xxxiii., 39-40.) 



ECZEMA. 175 

in others they were isolated throughout. In one case they began as 
"blisters ;" in all the others as dry papules. 

In all four patients, though the tumors were neither tender nor 
painful, the itching was severe — in two of the severest grade — the 
others (negresses) were presumably less neurotic in temperament. 
The pruritus, limited to the lesions present, seems to be an essential 
feature of the disease. In point of fact, the four cases on record 
seem more exact counterparts of each other than is often recognized 
in clinical medicine. 

Pathology. — The histology of the four cases is eminently alike. 
There is commonly, but not in all cases, thickening of the horny 
layer of the epidermis with fusiform cells apparent in the deeper 
strata. In the corium there are cell-nests and cell-columns spreading 
about the blood-vessels. These last are considerably enlarged. In 
some cases broad " horizontal trails " can be recognized in the sub- 
papillary layer. 

Course. — The disease is of exceedingly slow career lasting from 
fifteen to twenty or more years. The itching was intense in two 
cases ; in two it was less severe, both of these patients were negresses. 
My patient positively asserted that from the beginning, no single 
lesion after its full development had disappeared. In one case the 
lesions recurred after extirpation. That the nodules were not due 
in any way to scratching was made clear in Schamberg's and my 
cases. 

Treatment. — The nature of this rare disorder is obscure and no 
treatment has yet been advocated as effective. 

Prognosis. — The prognosis is in a high degree unfavorable, as 
regards the comfort of the patient. 

ECZEMA.* 

(Gr., ek S-iu, to boil forth.) 

(Ger., Eczem; Fr., Eczema.) 

Eczema is distinctly a protean disease". It is difficult, therefore, 
to define or describe it satisfactorily in a single paragraph. It is not 
only protean in its clinical manifestations, but its causes are varied, 
numerous, and usually complex. In histological detail different 
types of eczema vary considerably, yet all probably result from one 
common pathological process. Clinically, though a dozen successive 
cases of eczema may present wholly different pictures, yet they all 
have some characteristics in common and the diagnosis in most cases 
is not difficult. It has often been described as a catarrhal inflamma- 
tion of the skin, but while it is true that as a rule eczema shows at 

1 For a complete presentation of the subject, with full bibliography, the reader 
is referred to the chapters on " Eczema/' by Besnier, in La Pratique Derma- 
tologique, t. ii., pp. 1 to 305, and by Unna, in Mracek's Handbuch, Bd. ii., pp. 
169 to 393; also Duhring's Cutaneous Medicine, pt. ii., pp. 311 to 420, 



176 HYPEREMIAS AND INFLAMMATIONS. 

some time in its history more or less serous discharge, either in 
vesication or in a denuded oozing surface, many cases of the erythe- 
matous or papular type persist as such throughout their entire course, 
and never produce an exudate upon the surface. Eczema cannot 
therefore, be regarded as invariably catarrhal in nature. The fol- 
lowing definition seeks to embody, as adequately as possible, a proper 
conception of the scope and limits of the disease : 

Eczema is an acute, subacute, or chronic dermatitis, beginning as 
an erythema, or by the appearance of isolated or grouped papules, 
vesicles, or pustules, occurring in uniform, multiform, or modified 
types upon a reddened, generally infiltrated base; accompanied by 
more or less intense itching and burning sensations; resulting in 
catarrhal symptoms and crusting, in infiltration and scaling; and 
leaving, after complete resolution, no cicatrices. 

A vexed and unsettled question among dermatologists is the rela- 
tion of eczema to other forms of dermatitis. The study of the exact 
pathological changes in the skin has led to the inclusion under eczema 
of conditions formerly considered distinct affections. On the other 
hand, many writers, especially in England and France, are now en- 
deavoring to exclude from eczema every dermatitis for which a 
definite cause can be found. Eczema is a dermatitis, and it is not 
possible to say for every case which title is the more appropriate. 
A convenient, arbitrary division, which is followed in these pages, 
classes under dermatitis those forms of inflammation of the skin 
which result from recognized, external causes, and which subside on 
the removal of the cause. Such definite and independent affections 
as dermatitis herpetiformis or dermatitis repens are, of course, con- 
sidered separately. 

Symptoms.- — Eczema is one of the diseases of the skin of most 
frequent occurrence. In the statistics gathered by medical men it 
would seem to rank first in the order of frequency, forming from 
20 to 40 per cent, of dermatological cases reported. It i< undoubt- 
edly true that acne is a more common affection than eczema, but as 
many subjects of acne never deem it necessary to submit to treatment 
for its relief the records of such cases do not figure in dermatological 
statistics. This fact being noted, eczema may be regarded as the dis- 
ease of the skin for which the practitioner of medicine is consulted 
most frequently. By as much as inflammation is the commonest 
accident of other organs of the body, by so much is its enveloping 
organ subject to the same pathological process. 

The accepted signs of inflammation of any given tissue are usu- 
ally named as increased heat, redness, pain, and swelling. These 
symptoms are present to some extent in every eczema though modi- 
fied by the anatomical peculiarities of the organ in this case affected. 
The surface involved in typical eczema always shows some elevation 
of temperature, slight in chronic, but in acute cases possibly exceed- 
ing 105.5° F. (41° C). Redness, varying in shade from the 
bright red of the acute to the dull red of the chronic forms, is a 



ECZEMA. 177 

feature of the eczematous skin. Pain here is represented by a sensa- 
tion of itching which is almost invariably present and may vary 
from a slight annoyance to an almost intolerable distress. It is com- 
monly intermittent or paroxysmal in character and is usually worse 
at night. In some instances, especially in acute and erythematous 
types, the sensation of burning or smarting may be more marked 
than that of itching. Occasionally an eczematous skin is hyperses- 
thetic and exceedingly sensitive to contact with even the blandest 
substances. The degree and character of the subjective sensations 
in eczema depend largely upon the location, type, or severity of the 
disease, but also to some extent upon the general condition or pecu- 
liarities of the individual. In acute types of eczema there is often 
some oedematous swelling, together with slight infiltration of the 
skin. In chronic forms the infiltration and thickening of the skin 
are more pronounced and may be excessive. 

In addition to the symptoms of heat, redness, itching, or burn- 
ing, and swelling or thickening of the skin, found in every case of 
eczema, the great majority of eczemas have certain characteristics 
in common. The course of the disease is capricious, not only the 
severity of the process, but often the type of lesion changing fre- 
quently and rapidly. This is most conspicuous in children and in 
others having delicate skins, and in those cases in which the affected 
areas are not protected from atmospheric and other external influ- 
ences; it is unusual for eczema to pursue an even course. Daily 
variations in severity, with or without change or modification of 
type, are not uncommon. Apparent recovery is frequently followed 
by a relapse which may develop fully in a few hours and without 
apparent cause. 

Aside from some cases of erythematous and papular eczema, 
which may persist throughout without change of type, eczema is 
notably a polymorphic disease, presenting in irregular succession or 
in varied combinations: erythema, papules, vesicles, pustules, crusts, 
scales, fissures, excoriations, or denuded and oozing surfaces. Even 
in the mildest cases the skin is slightly infiltrated, while in some 
severe, chronic forms the thickening may be excessive and deforming, 
or there may be hypertrophy of all the layers of the skin producing 
wart-like growths. 

The serous discharge which is present during at least a part of the 
course of most eczemas is characteristic, and stiffens articles of cloth- 
ing on which it dries. It may be imprisoned in vesicles, but more 
commonly oozes from a denuded surface or from minute excoriated 
points which represent abortive or ruptured vesicles. 

Like all other inflammations, eczema may be acute or chronic. 
Like all others, too, the acute may precede, and the chronic may fol- 
low, or the reverse may occur. The disorder originating in sub- 
acute or insidious forms, may become chronic, and then, as the result 
of fresh or of more severe irritation, may develop the acutest symp- 
toms. Frequently, as in the eczema of children, the disease may 
12 



178 HYPEREMIAS AND INFLAMMATIONS. 

be chronic in respect to duration, yet most of the time present acute 
symptoms. As a rule, eczema does not undergo spontaneous recov- 
ery, but tends rather to remain indefinitely and to extend either by 
involving contiguous surfaces or by developing in new areas. The 
disease is commonly more or less local, appearing in one or several 
irregular and usually ill-defined areas, but may be general or even 
universal. It apparently occurs independently of all other disorders, 
the general health remaining unaffected even in severe forms of the 
disease; or it may be the external expression of constitutional dis- 
turbance. 

Clinically, several types of eczema can be recognized. These 
types require separate description. It should not be forgotten, how- 
ever, that in the majority of cases eczema is a complex process, in 
which two or more types are seen, either in succession or simultan- 
eously. Though several forms of eczema frequently coexist, it is 
usual for one type to predominate, either throughout the course of 
the disease or for certain periods. 

Eczema Erythematosum is most common on the face, especially 
in individuals exposed to wind and weather or to direct heat, but 
it may appear on any part of the body, and is frequently seen on the 
palms, the soles, and in the genital regions. It begins usually as a 
diffuse, ill-defined area of redness, less frequently as a number of 
coin-sized macules or erythematous spots, which may coalesce or re- 
main more or less distinct. Swelling and infiltration are present 
in varying degrees. In acute cases the oedema may be excessive, 
sometimes closing the eyes. In the subacute forms, which are the 
more common, there is less oedema and more infiltration and thicken- 
ing of the skin. 

The sensation of itching, which is so characteristic of most forms 
of eczema, is usually excessive, though it may be largely or wholly 
supplanted by one of heat or of burning. This is especially true 
when the process is acute in character. The color varies from a 
bright to a dull or purplish red, depending upon the severity of the 
disease, its location, and the peculiarities of the individual ; and in- 
asmuch as the condition is more frequently observed in middle-aged 
adults with darker hue of integument than in early life, the color of 
the part is often noticed to be of a dull-crimson shade. At times the 
coloration is irregularly distributed, producing a mottled appearance, 
bright at one point and dark at another. A yellowish tinge usually 
indicates that the process is combined with seborrhoea, producing 
the combination described in another chapter as dermatitis sebor- 
rheica. 

The erythematous surface is modified, as a rule, by more or less 
fine desquamation, which begins a few days after the occurrence of 
the first erythema, and persists to the end of the disease. There is 
no discharge, unless, as frequently happens, the type changes to a 
moist form; when the disease occurs on apposed surfaces, as in the 
axilla, under the breasts, or about the genitals, the superficial epider- 



ECZEMA. 179 

mis may be destroyed by maceration and friction, and leave a de- 
nuded, oozing surface. The disease may pursue an acute course, 
terminating in exfoliation and gradual resolution, or changing to the 
papular, vesicular, pustular, or mixed types. More frequently the 
process persists and becomes chronic. The skin then becomes more 
infiltrated and thickened, and may present voluminous firm folds, 
which are very conspicuous and often deforming. Exfoliation may 
be a pronounced feature. The area involved is frequently better 
defined than in other forms of eczema, and though the condition 
may remain limited to its original site for months or years, it has a 
decided tendency to extend either contiguously or by the formation 
of new areas. The intensity of the process may change frequently 
and rapidly. It is usually aggravated by exposure to heat, cold, or 
wind, or by any condition which favors congestion of the part. 
Scratching of the surface involved produces a change in the symp- 
toms which the skilled eye will promptly recognize. Minute super- 
ficial losses of tissue are then visible here and there upon the surface ; 
the more recent lesions having a reddened floor possibly hidden 
beneath a thin blood-scale, the older being surmounted by a light 
yellowish-red crust. The scratch-lines, often recognized elsewhere, 
are here less evident. 

Like all other varieties of eczema, this form is extremely liable to 
recrudescence and relapse. In advanced life traces of the disease 
may be visible for years. 

Eczema Papillosum. — Under this title are classed all those forms 
which have been described as Lichen Simplex, Lichen Eczematodes, 
Eczema Lichenoides, etc. In exceptional cases eczema may. exist 
from first to last as a dry infiltration of the integument. There is 
perhaps no one of the various manifestations of the disease that is so 
frequently confounded with other widely different affections. 

The papules are acuminate, pinhead-sized or larger, colored in 
various shades of red to a dark lurid shade, and are usually seated 
upon a reddened and thickened base. They are generally discrete, 
though often set closely together, are accompanied by an intense form 
of itching ; and of all eczematous lesions are most likely to be irritated 
by scratching. Their summits are torn, often to such an extent as to 
bleed, the blood drying in minute crusts on the apices of individual 
lesions. Existing papules may persist for weeks or may disappear 
and be replaced by others. They may coalesce completely to form 
irregular, thickened, elevated, pea-sized or larger patches, covered 
with scales. The areas involved in papular eczema are often fairly 
well defined in outline. The extent of surface affected varies, the 
disease being in some cases largely diffused over several portions of 
the body, but it is usually limited to small single patches no larger 
than the size of a small coin. Such patches, covered with a single or 
with several groups of reddish papules, may continue to torment the 
patient for long periods of time, or, being at one time relieved, may 
recur with each aggravation of the malady by the exciting cause. 



180 



HYPEREMIAS AND INFLAMMATIONS. 



Papular eczema is a dry manifestation of the disease, and is thus 
most frequently noticed upon the drier portions of the integument. 
If the moist forms of eczema are most frequently seen in early life, 
it is none the less true that the dry forms are the most common in 
adult life or in advanced years. 

The papules here described, when there is free exudation beneath 
the surface, may exhibit pin-point-sized vesicular summits which may 
develop into minute or larger pustules. A patch of papular eczema, 
where no vesiculation nor pustulation has been observed, will, if suffi- 
ciently scratched, ooze with moisture, the serum escaping from the 

Fig. 40. 




Eczema nuch;p (Licbenification). 



abraded surface. There are, in fact, few scratched eczematous sur- 
faces which will not moisten a handkerchief applied to the part. 
This weeping condition attracts the attention of patients themselves. 
A species of relief from pruritus is thus obtained ; and in aggravated 
cases patients will scratch or rub or otherwise irritate the diseased 
patches, not merely for the purpose of gratifying the intense desire to 
assuage the itching, but also to induce serous exudation for the sake 
of the relief it affords. 

Resolution of papular eczema is accomplished after the formation 
of scales, the tissues beneath the latter assuming more and more the 
appearance of healthy skin. 



ECZEMA. 181 

Eczema Vesiculosum is characterized at an early period by the 
formation of minute vesicles. It is a matter of importance, however, 
to recognize the fact that the vesicular, like the erythematous, is but 
one of several manifestations of this singularly protean affection. 
Long after the appearance of the treatises of early English dermatol- 
ogists the term " eczema " was very generally limited by physicians to 
the vesicular phases of the disease ; it is to the Vienna school that we 
are largely indebted for the recognition of the fact that these simul- 
taneous or successive features, presented often in the same individual, 
really belong to one and the same malady. 

The clinical features of vesicular eczema are chiefly due to the 
acuity of the inflammatory process present, and to the consequent 
free exudation of serum of the blood from the vascular plexus im- 
mediately below the pars papillaris of the corium. The involved sur- 
face usually feels at the outset hot, itchy, or unusually sensitive ; and 
soon after becomes more or less intensely reddened, the result of hy- 
peremia and subsequent exudation which may last for one or for sev- 
eral hours. Poppy-seed- to grape-seed-sized vesicles then become 
visible on this reddened base. The lesions may be closely packed to- 
gether, or be discrete, or may be so abundant as to coalesce, a frequent 
behavior of all vesicular lesions. Each vesicle is filled with a droplet 
of clear serum imprisoned beneath the most superficial layers of the 
epidermis. This vesicle is readily ruptured, and if this rupture does 
not speedily occur as the result of accident, the lesion bursts spontan- 
eously, and its limpid contents are then poured out upon the surface 
of the integument. The quantity of the fluid thus exuded is in excess 
of that originally contained in the small vesicular chambers, due to the 
fact that the excoriated, macerated, and broken epidermis no longer 
presents an obstacle to the outflow of serum from the engorged vessels 
beneath. Minute and even large drops of a clear fluid of syrupy con- 
sistency can be seen collecting at the points where the solution of con- 
tinuity has occurred. If with a slip of bibulous paper the first drop be 
removed, its place is visibly filled by a second. Crops of new vesicles 
succeed the first, each crop being followed by the train of symptoms 
described. The vesicles are usually short lived and often have dis- 
appeared before the patient is seen by the physician. In other 
instances the destruction of the epidermis by rubbing or scratching, 
or by an abundant and rapidly formed exudate, allows the escape of 
the fluid without previous vesicle-formation. The discharge dries 
rapidly, when exposed to the air, in light-yellowish crusts which are 
rarely bulky. 

The contour of the affected patch or patches is seldom well defined, 
the pathological portions imperceptibly shading into the sound skin. 
The color of the area thus diseased varies according to the stage of the 
process, being at one time a vivid red, at another yellowish, and 
when covered with crusts or scales, undergoing a corresponding 
change of hue. Infiltration of the skin occurs rapidly, so that when a 
portion of the affected integument is pinched up between the finger 



182 



HYPEREMIAS AND INFLAMMATIONS. 



and thumb it is found to be thicker and less elastic than normal. 
This form of eczema may persist or recur in a single small area, or 
it may spread and become diffused or even generalized. It appears 
commonly on the flexor and other surfaces where the skin is thin. 

The subjective symptoms of vesicular forms of eczema are more 
or less intense itching and often burning. In very acute forms there 
is considerable soreness, the patient managing the affected part with 
as much care as if it were a fractured limb. In exceptional cases, 
more frequently observed in children, there is sympathetic febrile 
disturbance of a mild grade. 

As resolution approaches, all the symptoms described above gradu- 
ally decline in severity; the serous discharge diminishes, the redness 
fades, the limits of the involved area become less distinct, the crusts 
loosen and fall, and beneath the scales which have taken the place of 
the oozing and broken epidermis a new and tender epithelial cover- 
ing is produced. As a rule, for weeks after the process has com- 
pletely ceased the newly formed epidermis has a slightly reddened 
and tender appearance, though complete resolution is followed by no 
permanent sequels. Instead of undergoing resolution the condition 
may terminate in eczema rubrum, in eczema squamosum, or in 
eczema pustulosum, this last form being ordinarily due to pus- 
infection. 

Eczema Pustulosum {Eczema Impetiginoides, Impetigo Eczema- 
todes). — This type may originate in one of the other forms of ec- 

Fig. 41. 




Eczema pustulosum (Infantile). (Fox.) 



zema, in consequence of the severity or acuity of the process, or be 
the result of secondary pus-infection, or pustular lesions may rapidly 
form at the onset. Usually there is first seen a crop of minute vesi- 
cles, which enlarge and become distended with puriform contents. 
These pustules either accidentally or spontaneously burst, and the 



ECZEMA. 



183 



fluid with which they were distended dries into yellowish-green or 
darker colored friable crusts. In aggravated cases the purulent mat- 
ter seems to form directly upon the involved surface. If the process 
be long continued, infiltration occurs, and the itching, which in all 
varieties of the disorder is a characteristic feature, is awakened as 
an accompanying symptom. The itching, however, is rarely of the 
peculiarly aggravated type accompanying the erythematous and pap- 
ular phases. Pustular eczema is most frequently encountered on the 
head, and in constitutions that do not readily resist the invasion of 
pus-cocci. When existing on the scalp and the face there is most com- 




Eczema impetiginosum. 



monly an involvement also of the sebaceous glands, the secretion of 
which, altered by the periglandular inflammation, is added to that 
naturally produced by the exudative process. Singular shades of 
mixed yellow and green and even black, are then to be distinguished 
in the resulting crusts, which later desiccate and fall, leaving a red- 
dened and tender new epidermis beneath. 

The four types of eczema considered above are, as has been stated, 
sometimes encountered in practice as distinct and unmingled forms of 
cutaneous disease, some of them more commonly than others. To pre- 



184 



EYPEEMMIAS AND INFLAMMATIONS. 



sent, however, a picture of eczema as it is seen clinically it must be 
understood that these several forms, useful in the analytical study of 
the disease, often become, in actual observation, well-nigh inextricably 
commingled. " Observation of the natural course of an attack of 
eczema," said Hebra, " furnishes the most unassailable proof of the 
connection between its various forms. In one case an eruption of 
vesicles begins the series of symptoms ; in another it is preceded by 
the appearance of red scaly patches or groups of papules; or vesicles 
and papules are developed together, some of the former rapidly chang- 



Fig. 43. 










^^^ ms ^£^* 






^^^^^^^B 


1 



Kiz.-nii pustulosum. (Fox.) 



ing to pustules and forming yellow gum-like crusts by the drying up 
of their contents." It is this constant interchange of features that 
distinguishes most eczemas from all other inflammatory affections of 
the skin. 

Eczema Rubrum. — This name has been given to the red and angry 
form of the disease, which, because of the free exudation of serum 
from the surface, has also been termed Eczema Madidans. In this 
form the highly inflamed, intensely red, and wounded integument, 
the horny layer of which has been destroyed and removed, pours out 
freely upon the surface a thick, gummy or syrupy fluid, which, if 
artificially removed, leaves behind it a swollen, angry, and still dis- 
charging skin ; or, being permitted to dry where it has formed, covers 
the surface with large flake-like crusts, which may be thin and yel- 
low, or thick, dark-colored, and often blood-stained. The crusts may 
remain but a few hours before an excessive outpouring of the fluid re- 



ECZEMA. 185 

moves them. There are thus displayed in frequent and rapid alterna- 
tion the discharging and the crusted surface. Eczema rubrum may 
occur on any part of the body, but especially in the flexures of joints 
or where two surfaces are apposed; another common site is the 
legs of elderly people or of those who stand much of the time. In 
this region the disorder is exceedingly chronic and rebellious to treat- 
ment, and eventually is accompanied by a great degree of infiltration 
and thickening which may go on to hyperplasia and produce a con- 
dition simulating elephantiasis. 

Eczema Squamosum (Eczema Exfoliativum) is marked by more or 
less redness, infiltration, and exfoliation of the skin. The scales 
are usually small, thin, whitish, and adherent. They may be scanty 
or quite abundant. Squamous eczema represents a low grade of 
inflammation, and is present as a transitory condition during a part 
of the period of resolution of all other types of the affection. It 
frequently persists, however, in the form of irregular, usually ill- 
defined, more or less infiltrated, dry, scaly patches. It is seen com- 
monly on the neck and face, at the border of the scalp, and on the 
limbs. 

Eczema Fissum (Eczema Rhagadi forme). — In eczema of the hand 
the movements of the fingers often produce fissures or cracks in 
the inflamed and infiltrated integument, and to those fissured forms 
the titles named above have been given. Fissures are observed where- 
ever an eczematous disorder has so impaired the elasticity and exten- 
sibility of the skin that its necessary movements, especially about the 
joints, tear and stretch the thickened integument. It is thus seen not 
only on the hands, but also on the arms, the feet, and about the ankles, 
the resulting rhagacles being, at times, the most painful of all the 
complications of the malady. It is seen frequently about the mouth 
and anus. Occurring upon the bodies and the hands of those who are 
compelled to come in contact with irritating substances, this form of 
the disease finds its severest expression. Mild, commingled forms 
of squamous and fissured eczema occur quite commonly on the hands 
and faces of persons whose skin is thin, tender, and poorly nourished, 
or exposed to wind, harsh soaps, hard water, chemicals, and other 
irritants. The condition is popularly known as Chaps or Chapping. 
In many instances these cases should properly be classed with Derma- 
titis Traumatica or Venenata. 

Eczema Craquele. — This is a rare form of eczema described by 
Trench writers in which a reddened surface is covered with large, 
thin flakes, or scales, separated and outlined in polygonal areas by 
superficial cracks or fissures. The condition usually involves a con- 
siderable surface of the skin, and is accompanied by itching and burn- 
ing and in most cases by hyperesthesia and an extreme sensitiveness 
to temperature-changes. It occurs chiefly in neurotic subjects. 

Eczema Intertrigo is a name applied to that form of intertrigo 
which, surpassing the limits of hyperemia, results in an exudative 
process. Reference is made to this possibility in describing the 



186 HYPEREMIAS AND INFLAMMATIONS. 

symptoms of erythema intertrigo. In eczema intertrigo the symp- 
toms are usually those of diffused redness of surfaces of the skin in 
close apposition, macerated by previous transudation of sweat, and 
weeping with the serum which oozes from several abraded points or 
patches. It chiefly attacks the obese of both sexes and all ages, and 
in advanced years the gouty. 

The flexor surface of the extremities, especially in the vicinity of 
the joints, as well as the inframammary regions, the interdigital sur- 
faces of the feet, and the axillary and inguinal spaces, are particularly 
prone to exhibit symptoms of this disease. In all such localities the 
alternate tension and relaxation of the integument serve, when the 
limbs are in motion, to increase the pruritus, and, correspondingly, 
to aggravate the disease. Often a certain proportion of symmetry 
can be perceived, the two popliteal spaces, for example, being simul- 
taneously affected, though each in a different degree. The parts 
most favorable for the complications of intertrigo are those nearest the 
trunk, where moisture and heat are greater, as the groins and the 
axillae, while the elbow and popliteal spaces are more frequently dry, 
exhibiting papulo-squamous ridges in lines at right angles to the axes 
of the limbs, with hypersemic patches on either side. 

Eczema Verrucosum, or the wart-like form of the malady, is oc- 
casionally observed, especially upon the lower extremities, in middle 
life or in advanced years, as the result of long-continued disease. 

The integi sn1 becomes thickened and so hypertrophied as to suggesl 

the appearance of warts closely packed together in a circumscribed 
patch. 

Eczema Sclerosum is most frequently observed upon the palmar and 
plantar surfaces, a condition referred to in the paragraphs relating 
to Asteatosis. In eczema sclerosum is presented a densely thickened 
inelastic integument, suggesting the condition of tanned leather, 
without the occurrence of any of the other lesions of eczema described 
above. As a consequence, perfect extension of the digits is impaired. 
Tuberculous Eczema of Nurslings, so called, is a term which has 
been applied to eczematoid eruptions about the mucous orifices of 
the eyes, nose, mouth, and ears, occasioned and sustained by morbid 
conditions of, and serous discharges from, those parts (otorrhcea, 
rhinitis, phlyctenular keratitis, etc.), and accompanied by oedema, 
vesiculation, and enlargement of lymphatic glands. The disease is 
characterized by rebelliousness to treatment and chronicity of course. 
This disorder is improperly named, since tubercle-bacilli have not 
been recognized in its lesions ; and because the symptoms above enum- 
erated may all be present when there is simply systemic nutritive 
failure and when no tuberculosis of other organs is present. 

Eczema Diabeticorum (Fr., Diabetides). — A singularly well-de- 
fined eczema is to be recognized about the genital organs o/those suf- 
fering from persistent or even transitory glycosuria, due to the irrita- 
tion produced by the passage over the parts, of urine charged with 
sugar. Women are often thus affected; and the condition is ac- 



ECZEMA. 



187 



companied by the most atrocious pruritus, excoriations produced 
by scratching, and enormous tumefaction of the ano-genital and sur- 
rounding integument. The local symptoms are chiefly those of 
eczema erythematosum, the surface being, as a rule, destitute of 
either vesicles or pustules. There are often a profuse serous dis- 
charge, considerable infiltration, and the production of inflamma- 
tory nodules over the engorged surface. 

Fig. 44. 




Eczema orbiculare. (Howard Fox.) 

Eczema Folliculorum. — Morris first described under this title a 
form of eczema which begins as an inflammation of hair-follicles. 
Each inflamed follicle projects from the surface in the form of a red- 
dened papule about which the skin becomes hypersemic. As the 
process spreads centrifugally by the involvement of adjacent follicles, 
the centre undergoes involution with desquamation, and a gradual 
change in color from red to yellow. This condition is found most 
frequently on the extensor surfaces of the legs and the arms, in multi- 
ple, scattered patches. The itching may be intense. This form of 
eczema is obstinate, and usually recurs. Morris considers it parasitic 
in origin and allied to sycosis. 

Eczema Parasiticum. — Under this title is included a large num- 
ber of cases the exact relations of which to the recognized types of the 
disease are still indeterminate. It is well known, for example, that 
the surface of the human body in health is the habitat of an enormous 
number of different parasites which are, for the most part, harmless 
or are effective as agents of disease only under certain specially favor- 
able conditions of the body. Cultivation-experiments with the flora 
found on the eczematous skin have revealed a large number of para- 



188 HYPEREMIAS AND INFLAMMATIONS. 

sites which together, if not singly, may be effective in producing some 
of its distinctive features. 

Eczema Marginatum is considered in the chapter descriptive of 
Ringworm. 

Acute Eczema. — An acute attack of eczema may be ushered in by 
malaise, chilliness, or the recognized symptoms of the febrile state. 
With or without these prodromata the affected portion of the skin- 
surface becomes the seat of a burning sensation which is soon suc- 
ceeded by redness and swelling. This tumefaction may occur upon 
one or upon several portions of the body at the same moment of time, 
and the disease throughout be limited to a single area or to several 
spaces; or it may extend from one to other or all regions. This 
extension may proceed by continuous development of the disease 
along the surface, or an eczema of the thigh may suddenly be followed 
by an eczema of the face, and this by an eczema of the scrotum. Ex- 
tension of eczema by the last-described course may occur when no 
constitutional cause can be discovered and undoubtedly is due largely 
to the extraordinary sensitiveness of the skin when involved in an 
acute attack, in consequence of which the slightest irritation produces 
a new focus of the disease at a distant point. This consideration is 
of special importance. Patients will frequently point to an acute 
eczema upon several portions of the body widely separated one from 
another, and will urge this as an irrefutable argument in favor of 
the fact that they suffer from some "poison in the blood." 

The tumid and erythematous surface above described soon as- 
sumes the features of one or more of the types of eczema outlined 
in the preceding pages. In this manner the evolution of the disease 
occurs, and may continue for weeks, the patient, if unrelieved, being 
tormented by the itching, and, if the disease be extensive, being pre- 
vented from attending to his usual vocation. Acute eczema of 
severe grade will frequently prostrate a strong adult, confining him 
to his bed-chamber and often to his bed. When there is a simultan- 
eous febrile process the emaciation and adynamia are proportioned 
to its severity. Weeks and even months may elapse before recovery 
can be pronounced complete, subacute patches of the disease lingering 
here and there upon the surface, crust-hidden, scale-covered, occasion- 
ally oozing from recrudescence of symptoms. Recovery, even when 
complete, leaves the patient, it should never be forgotten, with a skin 
sensitive to irritation and more prone to a fresh attack of the disease 
than one long virgin of an inflammatory process. 

Such is the course of an attack of acute eczema of severe grade. 
It must be remembered, however, that the process may be mild and 
subacute from the beginning, or again that a circumscribed patch of 
skin may exhibit all the features of vesicular eczema in an acute form, 
and under the influence of appropriate treatment may be relieved sat- 
isfactorily in the course of a few days. Lastly, acute or subacute 
eczema may be followed by chronic forms of the disease, the one 
passing into stages of the other by scarcely definable gradations. 



ECZEMA. 189 

Chronic Eczema.- — The symptoms and pathology of chronic 
eczema are largely those of the acnte form of the disease. The chief 
differences to be noted relate to diminished intensity of the inflamma- 
tory action, a marked tendency to recurrence and persistence of the 
process, and a preponderance of scaling and infiltration as contrasted 
with the active secretion and crusting of acute phases. It is impor- 
tant, however, to remember that chronic eczema is not only the fre- 
quent sequel of such acute phases, but is prone also to recurrent exac- 
erbations of acute grade, during which the serous discharges, conse- 
quent crusts, and angry aspect of the affected surface do not fail to 
reappear. The itching so characteristic of the malady in all its mani- 
festations is often more annoying than in the acute phases of the 



Chronic eczema may involve a limited region of the skin, or may 
invade the entire surface of the body from the head to the feet. 
Karely thus generally developed, it is more frequently observed upon 
circumscribed patches of the integument, as, for example, the scrotum 
or the flexor surface of a joint, in which situation it may linger for 
years or even for a lifetime, now better and now worse, or disappear 
for brief periods only to return with each recurrence of its cause. 

Etiology. — The tendency in modern dermatology to regard 
eczema as a dermatitis without obvious cause, or one which persists 
after the withdrawal of a recognized irritant, necessarily places an 
increasing emphasis upon the importance of etiology. What are the 
elements which produce the cutaneous inflammation ? or if a recog- 
nized cause has been removed, why does the dermatitis persist? The 
fact that eczema constitutes so large a proportion of reported skin 
diseases emphasizes the lack of knowledge of the factors which pro- 
duce it, and the rapidity with which some of these conditions are 
assigned to other categories will be a measure of the progress of ac- 
quisition of etiological facts. 

Some diversity of opinion exists among dermatologists as to the 
nature and pathogenesis of eczema. The views held have been 
grouped by McLeod 1 as follows: 

(1) Parasitic: that eczema is produced by certain organisms act- 
ing upon the skin. 

(2) Toxic: that eczema is the result of the action of irritants, 
operative externally or internally, in a susceptible individual. 

(3) Neurotic: that nerve-strain or tropho-neurotic influences are 
the efficient cause. 

(4) Cutaneous reaction : that eczema is a symptom merely ; a re- 
sponse of the skin to irritants without or within. 

It will be seen upon examination that these theories may practic- 
ally be expressed in one, namely, the second. The view that 
eczema is due to the action of internal or external irritants in sus- 
ceptible individuals is broad enough to include the others. Para- 

1 Practitioner, 1906, 77, p. 98. Gardiner makes a similar classification, Scott. 
Journ., 1904, November. 



190 HYPEREMIAS AND INFLAMMATIONS. 

sites produce toxines which may act locally or from within after 
absorption ; that nerve-action cannot be reduced to a final term, toxic 
action, has yet to be established; and the theory of cutaneous reac- 
tion necessarily presupposes a stimulus or irritant acting within or 
without. 

Eczema is a disease of both sexes and all ages. It is not in itself 
hereditary, for no child was ever born into the world with eczema. 
A tendency to the disorder, however, may be transmitted from parent 
to child though not made manifest until adult life. The elements 
of this hereditary predisposition are not entirely certain. They 
are probably in part metabolic and for the present, until knowledge 
of the physical and chemical intricacies of the human organ ism is 
materially extended, they may be grouped under the rather general 
term, diathesis. The tendency to eczema is very commonly observed 
in those subject to manifestations of gout, and in those who suffer 
from asthma, both of which are regarded as diathetic disorders. It 
must be assumed also that congenital anatomical peculiarities of the 
skin may act as predisposing elements by increasing cutaneous vul- 
nerability. 

The question of acquired predisposition to eczema is intimately re- 
lated to that of systemic irritation: in fact, the two are not separable. 
To the first may be assigned, in any given case, that proportion of 
the sum total of operative internal causes which expends itself in the 
reduction of the resistance of the skin, so that a slight irritant suffices 
to produce an eczematous attack. But this proportion is not a de- 
terminible quantity. Thus it U known that certain physiological 
states such as pregnancy or dentition, and many morbid conditions, 
predispose to eczema, but the eczema which develops is not due solely 
to the circulation of toxines within the body, nor does a definite pro- 
portion of this toxic cause reduce the resistance of the skin and the 
rest produce the eczema. For practical purposes all systemic causes, 
both predisposing and exciting, may be grouped together. 

Eczema may occur in individuals who are in every respect superb 
examples of health; but in the majority of cases it is associated with 
some disturbance of the general economy; and it often occurs in per- 
sons who are affected with many forms of bodily ailment, both acute 
and chronic. By what means these varied systemic disorders favor 
the development of eczema is not positively known. Part of their 
association with the cutaneous disease may be considered as coinci- 
dence. In some instances they constitute conditions which favor the 
production of disease in general, eczema not excepted. Their 
direct influence in the production of eczema may be regarded as oper- 
ating through the nervous, vascular, and glandular systems, upon the 
innervation, nutrition, secretion, and physiological growth and repair 
of the skin. The agencies by which this is accomplished may be con- 
sidered toxic, whether they arise within the system from imperfect 
metabolism, or are developed as the result of microbic invasion or are 
formed by the degeneration of cell protoplasm. 



ECZEMA. 191 

The theory of reflex irritation has been called into service to ex- 
plain the sudden appearance of secondary eczematous lesions at a 
distance from the original focus. The view holds that the inflam- 
mation of the skin is reflected from one place to another through the 
medium of the nervous system. A study of the elements which make 
up the inflammation complex seems to show that reflex nerve influence, 
without the aid of some toxic agency acting within the skin, cannot 
produce an eczema. 1 Cases which apparently lend support to the 
reflex theory can be fully explained by assuming, first, an uncon- 
scious transfer of an external irritant from the original site to other 
portions of the body; or secondly, a condition of systemic intoxica- 
tion which operates by so reducing the resistance of the entire skin 
that a trifling irritation at any point is sufficient to produce an 
eczema ; or thirdly, a lodgement within the skin, of an irritant, car- 
ried to the part by the circulation, or produced in situ through cell- 
degeneration resulting from trophoneurotic influences. Csillag's 2 ex- 
periments show that irritants applied to the skin produce a derma- 
titis at the area of contact, but in no other place, if care be taken 
to prevent accidental conveyance of the irritant to other regions. 
He holds that in four-fifths of all cases of acute eczema the cause 
can be shown to be an external agent, acting upon an oversensitive 
skin, and that lack of knowledge of the fact has led to the reflex 
theory. 2 

Among the conditions which are frequently associated with ec- 
zema, and which probably stand in causal relation to that disorder, 
may be mentioned the physiological states of pregnancy, lactation, and 
dentition ; systemic derangements which depend upon defects in diges- 
tion, assimilation, and excretion; impairment of circulation, gout, 
rheumatism, diabetes, nephritis, asthma, disorders of the liver, anae- 
mia, chlorosis, tuberculosis, and syphilis. The number might be 
extended to include all disorders which reduce the general vitality 
and therewith also that of the skin. 

The external causes of eczema are identical with those of der- 
matitis, and are chemical, mechanical, thermal, or actinic in their 
action. As stated on a preceding page, no sharp distinction can 
be drawn between eczema and any other dermatitis due to external 
causes, but those forms of dermatitis which persist after the removal 
of the external cause are probably due in part to, and are continued 
through, the action of other etiological factors, and are conveniently 
classed with eczema. It is doubtful if any of the local causes of 
dermatitis, acting for a limited period, could produce a persisting 
eczema without the cooperation of other conditions, either internal 
or external. The large majority of all externally operating causes 
of dermatitis fail to be effective in the mass of individuals. 

1 Cf. MeEwen, ' ' The Eelation of nerve impulse to cutaneous inflammation, ' ' 
J. A. M. A., 1906, xlvii, 8. 

s Archiv, 1902, lxiii., p. 213; and Orvosa Hetilap, 1906, 36; ref. in Monatsh., 
1907, 44, p. 253. Cf. also Fordyee, Journ. Am. Med. Assn.. 1903, June 13, p. 
1621; and Pinkus, Med. Klinik., 1906, No. 9. 



192 HYPEREMIAS AND INFLAMMATIONS. 

Respecting the numerous agencies operating thus externally and 
capable of producing the disease under consideration : they can all be 
referred to either solar light and heat, to contact with foreign bodies 
in various fluid or solid states, to toxic agencies of a widely differing 
nature, to traumatisms in varying degrees, and to the action of para- 
sites. Many of these agencies cooperate, some include others, and 
some become effective by aggravating a disease which others have en- 
gendered. The reader is referred to the chapters on General Etiology 
and Dermatitis for fuller consideration of this subject. It will be 
sufficient to note here that acids, alkalies, antimonial and mercurial 
compounds, mustard, sulphur, castor-oil, capsicum, arnica, turpentine, 
chloroform, ether, alcohol, and a long list of other medicaments are 
capable, when applied to the skin, of producing a dermatitis that, in 
susceptible individuals, will persist after removal of the cause, and 
may therefore be classed as an eczema. The same statement is true 
of articles manipulated in ninny of the trades — those, for example, 
handled by the grocer, the baker, the confectioner, the seamstress, the 
ink-manufacturer, the mason, the cook, the gardener, the laundress, 
the painter, the dyer, the printer, the tobacconist, and the chemist. 
Then, too, the eczema of the person exposed to severe cold, or to 
intense solar light and heal aided by reflection from water, or even 
to excessive artificial heat, as the fire of a furnace, illustrates the 
action of other causes named. Pressure- and friction-effects are 
exhibited in the inflammatory effects produced by contact with shoes, 
the edges of cuffs, trusses, crutches, and corsets. 

Scratching is a fruitful cause of the persistency of an eczema 
when the latter is well established. The experiments of Torek 1 and 
Roma 2 indicate that mechanical irritation of the normal skin, even 
in patients predisposed to the disease, will not produce a vesicular 
eczema, though in very sensitive skins a dermatitis with an exudate 
may result, and if the irritation be sufficiently prolonged, it may 
cause a lichenoid infiltration. 

Water is capable of exercising an injurious effect upon the skin 
to the extent of producing an eczema when applied externally as a 
fluid in excessively cold or hot temperatures, or in the vapors of 
Turkish and Russian baths or if it be rendered irritating by saline or 
other constituents. 

External causes of eczema are at times climatic, the disease being 
often worse during the cold seasons. Cold winds and sudden tem- 
perature-changes, especially from warm to cold, will often aggrav- 
ate and prolong an existing eczema. 3 

The external sources of eczematous trouble named above should 
be regarded simply as suggestive illustrations. Every contact with 
the external world sufficiently severe or prolonged to awaken the 
resentment of the healthy skin may be followed by the protest of the 

1 Archiv, 1902, lxiii., p. 27. 

2 Ibid., p. 39. 

3 Cf. references under General Etiology, p. 68 ; also Warde, B. J. D., 1903, 
xv., p. 349. 



ECZEMA. 193 

latter in the shape of an eczema; and the same may be true when 
even the most trivial external accidents occur to the sensitive skin 
of individuals especially prone to the disease. 

That many eczemas are modified in their course, and that some 
are caused, wholly or in part, by various micro-organisms, is undoubt- 
edly true. Aside from pus-cocci found in pustular eczema, however, 
no definite parasites have yet been demonstrated to be effective 
either in the production or in the modification of eczema. The 
healthy skin is the habitat of many forms of parasites, chiefly veg- 
etable, and every skin-lesion is open to infection with any one of 
the many micro-organisms with which it may come in contact ; hence, 
it is probable that the disease, once begun, is modified by secondary 
infections of one kind or another. Secondary pus-infection is fre- 
quently recognized, and the manner in which some forms of eczema 
respond to antiparasitic treatment leads to the inference that some of 
the many micro-organisms found in the lesions are active in the pro- 
longation, if not in the production, of the disease. Numerous para- 
sites, including the morococcus of Unna, have been cultivated and 
described as the cause of eczema, but their etiological relations to the 
disease have not been demonstrated. 1 

The probability that some forms of eczema are due to toxines of 
different micro-organisms is established by the experiments of Bender, 
Bockhart and Gerlach. 2 These observers in a long series of con- 
trolled experiments found that inoculation of the normal skin with 
cultures of staphylococci produced an impetigo or a simple pyodermia 
but when filtered bouillon cultures of the same organisms, which con- 
tained no cocci but only their toxines, were employed, the result was 
always a papulo-vesicular eczema of ordinary type. The primary 
vesicles so produced were sterile, but later contained staphylococci. 

Bockhart 3 believes that in individuals predisposed to eczema 
staphylococci may remain inert in the mouths of the follicles until 
some cause from without or within arouses them into activity. They 
then produce toxines which are diffused through the epidermis and 
produce eczema. The lesions so produced are invaded subsequently 
by cocci and other organisms, so that the later changes in eczema are 
due largely to other agencies. 

1 For a full discussion of the parasitic and other causes of eczema consult the 
Transactions of the Fourth International Congress of Dermatology, Paris, 1900 
(Gompt. rendu, XIII. Congr. Internat. de med., pp. 9-94) (abstr. in B. J. D., 1900, 
xii., p. 326); also papers by Morris, B. J. L\, 1898, x., p. 359; Eoberts, Ibid., 
1899, xi., pp. 7 and 66; Torok, Annales, 1898, s. iii., ix., p. 1073; and 1899, s. iii., 
x., p. 37; Sabouraud, Ibid., 1899, s. 3, x., p. 305; Leredde, Ibid., 1899, s. iii., 
x., pp. 30 and 438; Unna, Monatsh., 1899, xxix., p. 106; Galloway and Eyre, 
B. J. L\, 1900, xii., p. 307 (bibliography); Kromayer, Archiv, 1900, liii., p. 85; 
Scholtz et Raab, Annales, 1900, s. 4, i., p. 409; Whitfield, B. J. D., 1900, xii., p. 
406; Schwenter-Trachsler, Monatsh., 1903, xxxvii., p. 233; Engmann, Ameri- 
can Medicine, 1902, iv., p. 769 ; see also chapters by Besnier, La Pratique Dermato- 
logique, and Unna, Mracek's Handbuch. A brief summary is to be found in 
MacLeod's Pathology, p. 341. 

2 Monatsh., 1901, xxxiii., p. 149, 

3 Ibid., p. 421. 

13 



194 HYPEREMIAS AND INFLAMMATIONS. 

Pathology. — The pathological changes in eczema are those of 
inflammation of the skin, varying somewhat with the acuteness or 
chronicity of the process, and with the character and career of the 
exudate furnished in each expression of the disease. In most cases 
there is, first, a circumscribed or diffused hyperemia of the affected 
part followed by dilatation and congestion of the blood-vessels of 
the corium, exudation of serum, diapedesis of white blood-corpuscles, 
and oedema. 

The process probably begins in the papillary layer, from which it 
extends to the epidermis, to the deeper parts of the corium, and in 
exceptional cases inward even to the subcutaneous tissue. The 
cedematous infiltration may be quite extensive, producing marked 
swelling over considerable areas, or it may be slight and circum- 
scribed. At times it appears only about the hair-follicles, producing 
perifollicular papules. The cell-infiltration about the vessels of the 
corium is formed in part of leukocytes, some of which wander out- 
ward into the rete, but is probably composed largely of young connec- 
tive-tissue cells. 

The epithelial changes in eczema vary greatly with the stage, in- 
tensity, and type of the disease. Tt is not determined definitely if 
these changes are always dependent upon and follow the conditions 
described above in the corium, or if they are usually, or even rarely, 
primary in origin. It is probable that they are secondary to the 
vascular changes in the corium, though some observers, including 
Unna and Leloir, believe that in most cases the epithelium is first 
affected. In practically all forms of eczema there is a parenchy- 
matous oedema of the epithelial cells, especially of the transitional 
layers, as a result of which there is imperfect keratinization (para- 
keratosis) of the horny layers, the cells of which contain some mois- 
ture, retain imperfect nuclei, and are exfoliated in scales. In acute 
erythematous eczema running a brief course the epithelial changes 
may be limited to this parakeratosis, but in most cases they are 
followed by vesicle-formation in the upper part of the rete. The 
manner in which vesicles are formed is a matter of dispute. Some 
observers report that the first vesicles of acute eczema apparently are 
due to the formation in a number of contiguous cells of a clear space 
between the nucleus and the protoplasm, which enlarges until there 
is left merely a meshwork filled with serum. Other writers 1 state 
that the prickle-cells are forced apart mechanically by the intercellu- 
lar oedema forming small spaces. The vesicles so produced may be 
unilocular, but often are subdivided by remnants of prickle-cells into 
several chambers. The oedema may cause a separation of practically 
all the cells, producing Unna's " spongy metamorphosis " of the epi- 
dermis. The intracellular oedema described above follows. As a 
result of compression the prickle-cells about the vesicle may assume a 
spindle-shape. The vesicles, though usually superficially situated, 
may be found in any part of the rete. MacLeod states that they form 
1 Cf. MacLeod, Pathology, p. 101, 



ECZEMA. 195 

in the region of least resistance, which in eczema is commonly the 
superficial portion of the prickle-cell layer, but when the oedema ap- 
pears with unusual rapidity the greatest strain is put on the cells 
nearest the basal layer, where the vesicles then are formed. Again, 
the oedema may diminish somewhat, permitting the cells beneath the 
vesicles to become cornified, thus locating the vesicle entirely within 
the stratum corneum. The vesicles contain first serum with fibrin; 
later, leukocytes in varying numbers, more or less degenerated epith- 
elial cells, and nuclei. As a result of more active degeneration of cells, 
or of secondary infection, the vesicles become pustules, the contents of 
which dry on the surface, forming thick crusts. In very acute cases, 
with an abundant exudate, the horny layer may be raised from the rete 
to form vesicles or bullae. According to TJnna, vesicles in the later 
stages of eczema are due solely to an intercellular oedema. 

In eczema rubrum the horny layer is raised from the rete and de- 
stroyed without true vesicle-formation. The rete is thus exposed 
directly to the air, or is partly covered by an amorphous coating of 
dried serum and degenerated cells. 

In the later stages of eczema there is more or less hypertrophy of 
the rete (Unna's acanthosis), with corresponding enlargement of the 
papilla?, forming papules and elevated, thickened areas. In chronic 
cases the cell-infiltration and proliferation in the corium become 
very conspicuous, producing the thickening of the skin so charac- 
teristic of patches of chronic eczema. In these cases the papillae are 
larger than normal, and the vessels of the corium are dilated and sur- 
rounded by connective-tissue cells. The process may extend to the 
subcutaneous fatty layer, which then loses much of its fat, and be- 
comes dense and attached to the skin. Hypertrophy of connective 
tissue and lymphatic obstruction with elephantiasic changes may fol- 
low. In these cases the sebaceous and coil-glands and the hair-folli- 
cles may be partially or entirely destroyed by undergoing degenera- 
tion and atrophy. 

According to Ehrmann and Fick 1 three conditions, viz., acan- 
thosis, spongiosis, and parakeratosis are always to be found in eczema 
the degree of development of each varying with the type of the disease. 
The fluid exuded in eczema, in vesiculation, or in a free discharge 
from the surface, is always characteristic. Though in the earliest 
vesicles it is a simple blood-serum, it soon becomes a yellowish-white, 
sticky, and syrupy liquid, feebly alkaline in reaction and depositing 
albumin in abundance when treated with heat and nitric acid. Ex- 
posed to the air, it desiccates in light-yellowish to brownish friable 
crusts resembling honey or gum. 

Increase in the pigment-particles distributed to the epithelia of 
the rete is characteristic of the chronic forms of eczema, and more 
especially of those in which the circulation is somewhat impeded by 
the influence of gravity, as, for example, in the lower extremities. 
This increased pigmentation is true, however, of all diseases accom- 
1 Koiapendium der Speziellen Histopathologic der Haut, Wien, 1906. 



196 HYPEB&MIAS AND INFLAMMATIONS. 

panied by an augmented afflux of blood to any part of the body, as, 
for example, over the surfaces of joints to which for many years 
stimulating embrocations have been applied. 

Diagnosis. — Though of a dozen consecutive cases of eczema no 
two may look alike, yet they all have some characteristics in common 
and the diagnosis is usually attended with little difficulty. Eczema 
in its manifestations is such a protean disease and is, moreover, of 
such frequent occurrence, that it is necessary to establish a differential 
diagnosis between it and a large number of other cutaneous disorders. 
The more important of these are named below in alphabetical 
order for convenience of reference, the distinctive peculiarities of 
each being briefly appended. In making a diagnosis it must be 
remembered that eczema may coexist with any other disease of the 
skin, and that it very frequently thus complicates such cutaneous dis- 
orders as seborrhoea, psoriasis, and scabies. 

Acne. — Acne occurs chiefly on the face, the neck, and the back of 
the trunk, and its pustular forms may be mistaken for eczema of the 
same localities; but pustular acne is usually accompanied by a deeper- 
seated infiltration than the similar lesions of eczema, and this infil- 
tration is also generally limited to the sebaceous glands or the peri- 
glandular tissue. In eczema the itching is often severe, while in acne 
the subjective sensations are those of heat or burning. Comedones 
intermingled with the pustules of acne will aid in distinguishing 
the two. 

Erythematous eczema of the face is to be distinguished from 
Acne Rosacea by the more generalized infiltration of the former, its 
production of itching, and its greater diffusion over the face; while 
acne rosacea is limited more often to the cheeks, nose, and brow, and 
to the region adjacent to these parts. The patch of erythematous 
eczema is "hot," that of acne rosacea is cold, to the touch. The 
former is seen in infancy, the latter is rare in that period of life. 
Acne rosacea in many cases is distinguished readily by the develop- 
ment of visible blood-vessels in the skin of the cheeks or the nasal 
region. Lastly, in erythematous eczema the eyelids may suffer, while 
in acne rosacea this is the exception. In severe forms of acne the 
subepidermic pus-formation and the resulting scar will prove signi- 
ficant. 

Dermatitis. — Dermatitis of artificial origin is to be distinguished 
from idiopathic eczema rather by its history than by special differ- 
ences in the appearance or evolution of the lesions. In many cases 
the two affections are indistinguishable. A history of traumatism or 
of the external application of irritant or of toxic articles will often 
serve to distinguish the two. When the dermatitis has been produced 
by an externally' applied irritant the resulting inflammation of the 
skin will often exactly outline the area of contact. Dermatitis of 
artificial production is usually sudden in its onset, the date of which 
will nearly correspond with the time of operation of an exciting 
cause. The subsidence of the symptoms after the withdrawal of the 



ECZEMA. 197 

cause will also point to the nature of the affection. Eczema is also 
much more capricious in its distribution and career than dermatitis. 

Erysipelas. — Erysipelas is generally accompanied by febrile symp- 
toms ; in some cases bullae appear. The affected surface is reddened, 
much more swollen than in eczema, owing to the involvement of 
deeper tissues, and -it exhibits besides a characteristic shining ap- 
pearance, which is always absent in erythematous eczema. The line 
of demarcation between the affected and unaffected portions of the 
skin is usually distinctly defined in erysipelas, ill defined in eczema, 
and in the former disease is markedly tender. Erysipelas is an 
exceedingly acute affection and spreads from one point to another 
with a rapidity that is never noticed in eczema; the latter disease, 
moreover, usually exhibits under a lens its minute papules or vesicles. 
In eczema also, when occurring upon the face in the erythematous 
form, the scalp is usually spared, while erysipelas tends to invade the 
scalp and the regions covered by the beard. 

Erythema. — Eczema is to be distinguished from the forms of 
erythema which are due to hyperemia only by the presence of an 
inflammatory process. The erythema simplex which advances to exu- 
dation at once transgresses the artificial line of distinction between 
the purely congestive and the purely exudative disorders. It must 
therefore be remembered that many eczemas begin as erythemata, and 
that clinically the latter may represent but a stage in the morbid 
process. The discharge in erythema intertrigo results from impris- 
oned or from chemically altered sweat, and will not stiffen linen as 
does the serous exudation of vesicular eczema for example. Ery- 
thema multiforme, an affection really on the border-line between the 
two pathological classes here sought to be distinguished, will be 
recognized by the absence of severe itching and the recurrence of the 
disorder at certain special seasons of the year; while Erythema 
papulosum, E. tuberosum, and E. nodosum display solid elevations 
of the skin-surface much exceeding in size the minute lesions of 
papular eczema. 

Herpes.— Eczema is so associated with the occurrence of a vesicle 
in the minds of many that other vesicular disorders are likely to be 
confounded with it. But in herpes febrilis the vesicles usually are 
grouped about the mucous outlets of the body, and when actually 
under observation they exceed in size the minute and transitory 
lesions of vesicular eczema. In herpes zoster, with the limitation 
of the eruption in the course of a nerve to one side of the body and 
the production of grouped vesicles of a larger size and more persist- 
ent type, there is commonly a history of precedent or coincident neu- 
ralgic pain. The subjective sensation in the skin is a decided burn- 
ing rather than itching, and there is a possibility of the subsequent 
production of scars. 

Impetigo. — In these forms of disease the pustular lesions are usu- 
ally isolated, do not spring from an infiltrated surface on which other 
lesions may be visible, and are unaccompanied by the intense pruritus 



198 HYPEREMIAS AND INFLAMMATIONS. 

which is characteristic of eczema. The pustules, moreover, are larger 
and the resulting crusts as a rule, are bulkier and darker colored than 
those in eczema. Again, in pustular eczema the cutaneous affection 
usually occurs in one or more patches, while in impetigo a dozen or 
more isolated pustules may be irregularly scattered over the entire 
surface of the body. In impetigo there may be a history of extension 
of the disease from one member of a family to another. 

Lichen Planus. — Papular eczema may be confounded with lichen 
planus, but in the latter disease the typical papule has an irregular or 
polygonal base; a flat or umbilicated apex, which is covered with a 
thin, closely adherent, varnished-looking scale; and a violaceous or 
dull-crimson hue. The papules of eczema have round or oval bases, 
acuminate or rounded summits, and are brighter red in color. They 
also form more rapidly and undergo change of type more frequently 
than the more persistent papules of lichen planus. The patches of 
lichen planus are more sharply defined than those of eczema and are 
usually angular or linear in outline. The lesions of lichen planus 
on disappearing leave a characteristic brown or sepia-tinted pigmen- 
tation. 

Lupus Erythematosus. — Lupus erythematosus greatly resembles cer- 
tain forms of squamous eczema. The great chronicity of lupus ; the 
firm attachment of the scales; the symmetrical distribution of many 
patches upon the face; the association of some forms of the disease 
with the sebaceous glands ; the definite border of each involved area ; 
and, above all, the discovery of a cicatrix left by the morbid proce— . - 
will sufficiently distinguish the disorder. In eczema there are usu- 
ally itching, often vesiculation, more rapid extension of the borders 
of a single patch, and scales much more loosely attached than in ery- 
thematous lupus. The scales of eczema are never provided, as in 
lupus erythematosus, with stalactitiform plugs on the inferior surface. 
Lupus Vulgaris. — Lupus vulgaris is readily distinguished from 
eczema by its more chronic career, by its larger papules and tubercles 
of dark reddish-brown hue, and by every one of its destructive pro- 
cesses, none of which is ever recognized in eczema. 

Mycosis Fungo'ides. — Mycosis fungoi'des, in its earliest stages, may 
be indistinguishable clinically from some forms of localized or even 
generalized eczema. As a rule, however, the early erythematous and 
eczematoid lesions of mycosis fungo'ides can be recognized by their 
characteristic gyrate outlines, assuming, as they do, the shape of a 
kidney, horseshoe, half-moon, and other fantastic, more or less circin- 
ate forms. These figures may change frequently in form and location, 
or may disappear spontaneously, to return in the same or in new 
sites. They differ further from eczema in being located on any or 
every part of the body, independently of external influences, and in 
failing to respond to treatment during months or years. After the 
formation of characteristic thickened and elevated plaques the diag- 
nosis is not difficult. 

Pediculosis. — As eczema is often induced by lice upon the head, 



ECZEMA. 1 99 

the pubes, or the clothing, it is always necessary to exclude the opera- 
tion of such causes for both diagnostic and therapeutic purposes. 
Eczema limited to the pubic region or to the pubic and axillary 
regions should suggest careful examination of the skin and the hairs 
for the discovery of the crab-louse. As for the pediculus corporis, 
it should be the rule of the physician (whatever the social position or 
refinement of his patient), to search in a suspected case for evidence 
of the parasite upon the under surface of the clothing worn next the 
skin, at the instant of its removal and while the patient supposes 
him to be busied with the inspection of the cutaneous lesions. The 
excoriations produced by scratching wounds inflicted by body-lice are 
usually out of all proportion to the amount of skin-disease present; 
and this excoriation is the most significant of all symptoms next to 
the discovery of the corpus delicti. Head-lice may precede or may 
follow eczema of the scalp, but either they or their ova (nits), cling- 
ing in numbers to the hairs, will be visible to him who looks carefully 
for them. 

Pemphigus and Pityriasis Rubra. — The large isolated bullae of pem- 
phigus vulgaris are never seen in eczema. In pemphigus foliaceus 
the lesions are succeeded by the formation of pastry-like crusts, serous 
exudation, considerable soreness, and the eventual production of an 
extensive and often fatal exfoliative dermatitis. Marasmus grad- 
ually or in some cases rapidly ensues, while, as a rule, itching and 
infiltration are not present. The disease known as pityriasis rubra 
is equally rare and fatal, and, though unattended with the produc- 
tion of bullae, is characterized by an abundant epidermic exfoliation ; 
itching and infiltration being either entirely wanting or insignificant 
in comparison with the other symptoms present. The scales, too, are 
papery, large, and thin; there is no vesiculation and moisture, and 
little, if any, infiltration of the skin. The integument is, moreover, 
of a uniformly reddish hue. Both pemphigus foliaceus and pity- 
riasis rubra are particularly liable to be complicated with chills or 
with uncontrollable diarrhoea. Without question, many of the re- 
ported cases of so-called " pityriasis rubra " are instances of squamous 
eczema or of simple exfoliative dermatitis. Here the limitation of 
the disease to one or more patches upon the body, the severe itching, 
and the distinct infiltration of the patch point to the eczematous char- 
acter of the disease. Observation of such patients will finally con- 
vince the physician, in many cases, that there is occasional weeping 
from the surface. 

Pityriasis Rubra Pilaris often resembles in a high degree, and it 
may indeed be confused with, the squamous forms of eczema. In 
general there are not found in eczema characteristic lichenoid 
papules formed about the hair-follicles, with their hyperkeratinized 
cap sheathing the follicular orifice. Nor is the selection of the ex- 
tremities, and especially the dorsal aspect of the fingers, characteristic 
of eczema. In eczema there are usually distinct marks of scratching 
that may wholly be wanting in pityriasis rubra pilaris ; and the latter 
has in most cases a more chronic course. 



200 HYPEREMIAS AND INFLAMMATIONS. 

Prurigo. — In the prurigo of Hebra, a disease exceedingly rare in 
America, there are infiltration, intense itching, and numerous minute 
and larger papules. But this disease usually occurs within a year or 
two after birth and lasts for a lifetime, extending generally over the 
greater part of the body, sparing only the palms and soles (which 
eczema does not), and is accompanied by inguinal adenopathy. 

Pruritus. — In pruritus, often confounded with prurigo, there is 
itching without lesion of the skin save that induced by scratching to 
relieve the sensation. Hence, pruritus without scratching will not 
reveal a cutaneous disease, while pruritus with scratching will ex- 
hibit either excoriations or a dermatitis induced by the attacks 
made upon the skin. The former condition, however, is rarely noted. 
The distinction will be clear when it is remembered, first, that pru- 
ritus is usually of a paroxysmal character, being worse regularly at 
certain hours or seasons ; second, that pruritus not originating in a 
cutaneous lesion, but indirectly producing the latter by the medium 
of the finger-nails, never exhibits as much cutaneous excoriation as 
the skin bitten by lice or attacked with eczema. The impressive 
features here are always the disproportion between the complaint of 
the patient and the visible symptoms, and the vast preponderance 
of all lesions in those regions of the body most accessible to the hands, 
such as the anterior faces of the limbs, the genital region, the lower 
belly, etc. 

Psoriasis. — Psoriasis and eczema in typical forms are distinct. 
Variations in type from one to the other furnish many obscure cases. 
The following are the chief diagnostic points in psoriasis: sharp 
definition of contour of patch ; abundance and lustrous hue of the 
scales; absence of moisture; vascularity of tissue beneath the scales; 
sites of election on posterior aspect of the trunk and extensor surfaces 
of limbs; chronieity in course; uniformity of lesions; and usually 
absence of itching. In eczema there are an ill-defined contour; usu- 
ally scanty scales not having a nacreous hue; a preference for the 
flexor surfaces of the extremities, though the disease may occur in 
any portion of the body ; generally, at some period in its course, a 
history of moisture; polymorphism, as regards lesions; and a marked 
intensity of subjective sensations. Upon the scalp psoriasis is prone 
to extend beyond the hairy border in a fillet stretching across the 
upper portion of the forehead, thence irregularly down in front of 
the ears; while eczema of the face, when the scalp is also invaded, 
departs boldly from the hairy parts to the lower forehead, the lips, 
nose, cheeks, or chin, regions which are relatively spared by psoriasis. 
Finally, the two diseases, in doubtful cases, will generally be dis- 
tinguished by carefully searching the entire surface of the body, upon 
some part of which in psoriasis there will usually be discovered a tell- 
tale patch of typical appearance. 

Scabies. — Scabies is really an artificial dermatitis induced by the 
incursions of the acarus scabiei, and its lesions are thus very 
similar to those of eczema. In scabies, however, the pruritus is 



ECZEMA. 201 

intense and the recently formed papules, vesicles, and pustules 
are more distinct and isolated than in eczema. The discovery of 
the parasite, especially if there be a history of contagion, and the 
localization of the disease in its sites of preference, will at once de- 
termine the diagnosis. Scabies never attacks the scalp. Its sites of 
preference are in both sexes the fingers, hands, wrists, and axillae; 
in women the breast and the nipple ; in men the penis ; and in child- 
ren the buttocks. The presence of the acarian furrow, if the disease 
has existed for some time, and the appearance of minute blackish 
dots or points upon or about the lesions, usually suffice to establish the 
nature of the disease. 

Seborrhea. — Seborrhcea and eczema may coexist, either disease 
preceding the other. Typical forms of each are readily distinguished. 
In eczema there are infiltration and much consequent itching ; in seb- 
orrhcea there is neither. The scales of seborrhcea are more volumin- 
ous and greasy than those of eczema, are freely shed from the sur- 
face, and are seated usually upon an integument of scarcely altered 
hue; in eczema the scales are dry, scanty, and more firmly attached 
to an hypersemic base. Seborrhcea of the hairy parts is generally 
symmetrically diffused; eczema, though occurring with ill-defined 
contour, is rarely as symmetrical, usually more acute, and is seldom 
followed by alopecia. Upon non-hairy portions of the body the same 
distinctions to a great extent can be observed. The crusts of eczema 
removed from the face generally disclose beneath them an oozing sur- 
face, while the under surface of these crusts never exhibits the stalac- 
tite-like prolongations which pass from the under surface of sebor- 
rhcei'c crusts into the patulous orifices of the excretory ducts of the 
sebaceous glands. In dermatitis seborrhceica the features of both 
diseases are almost completely fused. 

Sycosis. — Both the hyphogenous and the coccogenous forms of 
sycosis are limited to the region of the beard, while eczema of the 
hairy portions of the face will usually be found to affect other parts. 
In eczema the itching is severe, the exudation spreads beyond the 
limits of the beard, and the discharge is characteristic; while in 
both forms of sycosis there is less oozing and the subjective symp- 
toms are trivial. The discovery of the parasite in the root or the 
shaft of the hair will at once distinguish the hyphogenous forms of 
the disease. In coccogenous sycosis each pustule is perforated by 
a hair. Eczema limited to the region of the beard is even rarer than 
the two varieties of sycosis. The circumscribed indurations and 
tuberculations of the affection produced by the trichophytons, as 
well as the loosening of the hairs in their follicles, constitute further 
distinctive differences. 

Syphilis. — Several syphilitic eruptions resemble certain forms of 
eczema. In the eruptions due to syphilis, however, there is usually a 
history of infection; of involvement of the glands and mucous sur- 
faces; of ulceration and cicatrices in advanced periods, and, espe- 
cially in the case of infants with an eczema-like eruption, a his- 



202 HYPEREMIAS AND INFLAMMATIONS. 

tory of snuffles. The intense itching of eczema is characteristic of 
no one of the syphilides, and the latter are remarkable for their ten- 
dency to occur with a circular or partially circular outline, and to be 
covered with bulky malodorous crusts. A point worthy of note is 
that compared with chronic eczematous affections a syphilitic eruption 
limited for an equal period of time to one locality will often ulcerate 
or exhibit evidences of repair by scar-tissue, no such results occurring 
in eczema. 

Syphilis of the palms and soles exhibits very distinct outlines in 
the usually circular, circumscribed, and deeply infiltrated patches 
present, which are often symmetrical in development, or are at least 
situated on both sides of the body even if more fully developed upon 
one limb. Syphilitic pustules upon the scalp usually rise above 
superficial but well-defined ulcers. Syphilitic eruptions encircling 
the mouth in children are less angry-looking and formidable than 
those of severe eczema of the same region, being often made up of 
flattened papules, moist or scaling, grouped in circles about the lips, 
with mucous patches at the angles. 

Tinea Circinata. — In ringworm there should be a history of con- 
tagion, microscopical discovery of the vegetable parasite, distinct con- 
tour of all separate patches, and absence of marked subjective sensa- 
tions and of discharge. These symptoms are not those of eczema. 
In ringworm of the scalp the hairs loosened in their follicles are usu- 
ally either brittle or are actually broken at a short distance from the 
scalp ; the scales are fine, dirty white, and not torn from the surface 
by the finger-nails. In eczema the hairs are unaffected, and their 
extraction is productive of pain. In ringworm of the body the 
patches are distinctly circular, are more scaly or papular at periphery 
than centre, and, moreover, yield with promptness to the action of a 
parasiticide. Occurring about the thighs and ano-genital region, the 
disease may be complicated by eczema, but the characteristic "fes- 
tooning" of the advancing border of the patch downward along the 
thigh, or upward over the pubes, will suggest a microscopical exam- 
ination of the scales scraped from the surface. 

Tinea Favosa. — The large, friable, dirty crusts of an old and 
neglected favus of the scalp might be mistaken for the crusts of 
eczema of the same part ; but here the exudation is slight, and there 
is little scratching, as in eczema, hence no history of discharge. The 
odor, moreover, is peculiar. In case of uncertainty a careful search 
would reveal a few characteristic cup-shaped and yellow crusts or the 
microscope would demonstrate the parasitic nature of the disorder. 

Tinea Versicolor. — In this disease, also, the microscope will reveal, 
beneath the epidermal plates, the spores and filaments of the fungus 
which produces the ailment. From eczema the disease is easily dis- 
tinguished by the absence of infiltration and of any history of in- 
flammation; by the very slight subjective sensation it produces; by 
its peculiar fawn- to chocolate-colored, slightly yellowish patches, 
which are covered with superficial furfuraceous scales, are limited 



ECZEMA. 203 

to the covered parts of the body and often to the anterior surface of 
the trunk, and are readily removed by the action of a parasiticide. 

Urticaria. — In papular forms of the disease there may be a re- 
semblance to eczema. This resemblance is more marked in children, 
as here the two diseases may be intermingled. Characteristic wheals 
often occur by the side of eczematous patches, but, as a rule, urticarial 
lesions are less grouped, more generally disseminated, more evanescent 
and much less scratched. 

Treatment. — The treatment of eczema usually presents a compli- 
cated problem. The causes of the disease are numerous, frequently 
obscure, and when discovered are often difficult to remove. Eczema 
shows little tendency to spontaneous recovery, but tends rather to 
persist, to spread to contiguous or distant parts of the body, and to 
recur. Although many cases of the disease respond well to local 
treatment alone if the affected surface can be given absolute rest and 
kept constantly covered with the desired dressing, such ideal treatment 
can rarely be carried out except in hospital-patients. Moreover, in 
many cases of eczema the general health of the patient must be im- 
proved before local treatment can be effective. The nutrition and 
functional activity of the skin depend largely upon the condition of 
the general system, for the skin is but one of many organs in a com- 
plex organism. It follows also that every serious disease of the skin 
must interfere more or less with the general health. The fear that 
too rapid a cure of eczema may result in disease of deeper-seated 
organs is baseless. The sudden improvement or disappearance of an 
acute eczema coincidently with the development of a pneumonia or 
other grave disorder may be explained by the rapid withdrawal of a 
large amount of blood from the skin-surface to the newly congested 
organ. The improvement in the eczema is thus a result and not a 
cause of the deeper-seated disease. 

The treatment of eczema requires both local and constitutional 
management. 

Constitutional Treatment. — In many cases internal treatment may 
be wholly ignored, and eczema be successfully controlled by local 
measures alone, even though there be coincident systemic disease. 
Often, however, the eczema is an external expression or result of other 
pathological conditions which must be removed before the eczema can 
be permanently cured. These systemic disorders vary widely, rang- 
ing through the whole field of internal medicine and hygiene. In 
these pages a few suggestions only can be given regarding the internal 
treatment of eczema, much being left to the practitioner's knowledge 
of general medicine. It is often necessary not only to relieve disease 
of other organs, but also to study the patient's temperament, habits 
of eating, drinking, bathing, sleeping, etc., before an obscure cause of 
stubborn eczema can be found and removed. 

Diet. — ~No absolute rule can be laid down regarding the diet in 



204 HTPEB^MIAS AND INFLAMMATIONS. 

eczema. Each individual should be given the quantity and quality 
of food that will best nourish his body without interfering with diges- 
tion and elimination. The anaemic, strumous, and poorly nourished 
subject should be given sufficient fresh beef, mutton, eggs, milk, cream, 
vegetables, and other nourishing foods. Cod-liver oil, butter, and 
other fats, when easily digested, are of special value, as also are the 
various malt-preparations, particularly when digestion of the carbo- 
hydrates is at fault. In the plethoric, the overfed, the gouty, and in 
those suffering from faulty digestion and elimination, a diet restricted 
to the lowest point consistent with the health of the individual is often 
of the greatest importance. In these cases excellent results are ob- 
tained by limiting the patient to a diet of bread and milk, or of milk 
alone, or of milk and seltzer-water, for several weeks. In general, the 
diet allowed the eczematous patient should be limited to the most 
digestible articles of food and should exclude those (a list of which is 
given in the chapter on Urticaria) capable of exciting cutaneous irri- 
tation. Cooked vegetables, fruit, and a small quantity of fresh 
meat may be permitted ; but starchy articles in excess, hot breads 
and cakes, pastry, confectionery, cheese, pickles and pickled meats, 
the heavier vegetables, shell-fish, salted fish and meats, pork, and veal 
should be avoided. Coffee, tea, and cocoa are in the doubtful list, as 
they are positively injurious to some patients and apparently without 
effect in others. Water, as free from mineral constituents as procur- 
able, may be taken freely between meals. Tobacco should always be 
forbidden to male patients suffering from a serious eczematous attack. 
Alcohol in every form is contraindicated save in condil ions of debility, 
or in case of its previous habitual use in moderation by persons of 
advanced years. In gouty patients the dietary should be of the 
strictest appropriate to that condition, and in diabetic eczema the 
regimen proper in glycosuria is observed with great benefit in most 



Internal Medication. — There are no specifics for eczema. 
Such remedies only should be given as are indicated by the general 
condition of the individual. Over-medication and uncalled-for dos- 
ing with " blood " medicines is a common error in the management of 
this disease. The number of patients presenting themselves for 
treatment of eczema, both in dispensaries and hospitals and in private 
practice, who have aggravated their condition by medicaments they 
have swallowed is incredibly large. Striking results are often ob- 
tained by merely setting aside the operation of these mischievous 
medicinal agents. The chief object of the constitutional, and also 
of the local, treatment of eczema is to remove all sources of irrita- 
tion of the inflamed skin. 

An attempt to relieve pruritus by the use of anodynes internally 
is rarely necessary, and usually aggravates the disorder. Opium 
and its preparations increase the pruritus, though in full doses they 
relieve temporarily. With some patients and especially children, 
full doses of quinine may relieve itching. Aspirin is of value as an 



ECZEMA. 205 

anti-pruritic. Less frequently full doses of calcium chloride, largely 
diluted with water, may serve the same purpose. In an emergency, 
chloral, phenacetin, sulphonal, or even the bromides, may be given, 
but like opium, they all are liable to aggravate the pruritus after a 
first anodyne effect has passed. 

In the management of acute eczema cooling draughts are use- 
ful ; and in all cases occurring in patients who are plethoric, or con- 
stipated, or who suffer from other symptoms of imperfect excretion, 
aperients and cathartics are needed. Often a brisk mercurial purga- 
tive in the form of blue mass or the compound cathartic pill may be 
ordered at the outset. Five grains (0.33) of blue mass or one to three 
grains (0.06-0.2) of calomel may be given each night, followed by a 
saline laxative in the morning, for several successive days, or once 
every third or fourth day. A tenth of a grain (0.006) of calomel com- 
bined with sodium bicarbonate may be given every hour for a day or 
two, and then three or four times daily for two weeks or longer, if at 
the same time salines are used to keep the bowels freely open. The 
rhubarb-and-soda mixture answers well in some cases. Podophyllin, 
or the familiar combination, nux vomica and aloes, may be sub- 
stituted for these articles. The saline cathartics, whether employed 
in medicinal formulae or in natural mineral waters, such as the 
Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are exceed- 
ingly useful in the management of most cases. The following is a 
valuable combination often advised for cases in which both iron and 
magnesium sulphate are indicated: 

I£ Magnes. sulphat., 

Acid, sulphur, dil., 

Ferri sulph., 

Sodii chlorid., 

Cardamom, tinct. comp., 

Aq. dest., ad Oss; 240 M. 

Filtra. Sig. — A tablespoonful before breakfast in a tumblerful of cool or 

of hot water. 

An excellent remedy for some cases is from 15 to 20 drops of a 
fluid containing 2 parts of the fluid extract of cascara sagrada to 
1 part each of glycerin and tincture of aloes, the dose to be taken at 
bedtime or before breakfast in a small glassful of water. A full dose 
of castor-oil on retiring is an excellent remedy in many neurotic cases, 
and may be continued for weeks if needed. 

In some cases of renal derangement the alkaline diuretics are indi- 
cated, such as potassium acetate, carbonate, or citrate, administered 
with nitre, squills, caffein, or lithium benzoate in from 3 to 5 grain 
(0.20-0.33) doses before meals, and in gouty cases colchicum, 
Vichy water, etc. Distilled or other pure water, or in suitable cases 
the alkaline spring-waters, taken in large quantities before meals and 
between meals, are very valuable as diuretics and as a means of 
encouraging elimination. In patients suffering from acid dyspepsia 
liquor potassse, sodium bicarbonate, ammonium carbonate, or milk 
of magnesia may be required, Salol and other intestinal antiseptics 
are often of value. 



f3ij; 


60 


8 


3ss; 




3j; 


4 


f3iv; 


15 


ad Oss; 


240 



3«; 


15 




3.i; 


4 




f3ss; 


2 




TTLiij ; 


2 


f3vj; 


180 


M 



206 EYPEUMMIAS AND INFLAMMATIONS. 

Aloes and iron, or aloes and ergot, are indicated in special cases. 
Where diuretics and alkalies are both indicated the following for- 
mula is often of service: 

$ Magnes. 8ulphat., 

Magnes. carbonat., 

Colchici tinct., 

Menth. pip. ol., 

Aq. des., 
Sig. — Two tablespoonfuls in a wineglassful of water every three or four 

hours. 

Cod-liver oil is indicated in all cases of struma and tuberculosis; 
calcium phosphate in bronchitis; iron in anaemia and chlorosis; 
strychnine, hypophosphites, and other nerve-tonics in neurotic cases. 
Antimony in small doses as an alterative and nerve-tonic or in large 
doses to reduce vascular pressure is often of value. 

In fleshy children affected with eczema calomel internally is a 
valuable remedy;. from % grain to 2 grains (0.03-0.133), with 2 to 
3 (0.13-0.20) of rhubarb, rubbed up with 5 grains (0.33), of cal- 
cined magnesia, may be given once in a day to an infant ; or %o of a 
grain (0.003) of calomel, rubbed up with sugar of milk, may be 
given, three times daily, for ten or twelve days. Small doses of the 
unspiced syrup of rhubarb, with or without magnesia, may be 
required for the constipation of infants, or from 1 to 3 drachms 
(4.-12.) each of powdered rhubarb and sodium bicarbonate in 4 
ounces (120.) of peppenniiit-wator, of which a teaspoonful may be 
administered two or three times or oftener daily. Quinine, strych- 
nine, syrup of ferrous iodide, and wine of iron may also be used with 
advantage when indicated in these little patients. 

Beside those enumerated above may be named the following 
articles, which, after internal administration, have been reported as 
efficient in the hands of various authorities: calx sulphurata, viola 
tricolor, sodium hyposulphite, ichthyol, chrysarobin, tar, carbolic 
acid, sulphur, pilocarpine, and turpentine. Arsenic, which has 
been so largely employed by the general practitioner in eczema and 
in other disorders of the skin, is an uncertain remedy in all cutaneous 
diseases; it is equally uncertain in eczema, and has unquestionably 
aggravated as many cases as it has relieved. Its value in some 
chronic papular and squamous forms of the disease is undoubted, 
and in small doses as a nerve-tonic it is often of value, but it should 
never be given in acute cases or where there is any digestive dis- 
turbance. 

Sunlight, fresh air, suitable clothing, and due regime as to 
pleasure and business, must be, for many patients, controlled by the 
physician. These agencies do not cure eczema ; but they do much to 
aid in its management; they may do more, if neglected, to permit 
its aggravation. Crocker advocates counter-irritation over the spine 
— over the nape of the neck for eczemas of the upper segment 
of the body; over the dorso-lumbar vertebrae for the lower parts. 
Jackson has used the ice-bag with advantage in the same way. Coun- 



ECZEMA. 207 

ter-irritation of the corresponding part of the lateral half of the body 
for the relief of an eczematous patch of long standing limited strictly 
to the other side may also be employed in rare cases. 

Local Treatment. — Local treatment is of value in all cases of 
eczema, is usually imperative, and often is the only treatment neces- 
sary. The remedies recommended for external application in the 
various forms and phases of eczema are so numerous and varied that 
barely to mention all would require many pages; and not even the 
expert can be sufficiently familiar with them all to use each intelli- 
gently. A comparatively small number of remedies skilfully handled 
will suffice in all but rare cases. It often happens that in a given 
type of the disease a treatment which one physician uses with 
brilliant success fails utterly to serve a fellow-practitioner who is 
equally skilful, but who is less familiar with this particular method. 
One of the most common errors in the local treatment of eczema lies 
in the frequency with which, in a difficult case, a succession of new 
medicaments is tried instead of studying more carefully the details 
of application of familiar remedies. It must not be forgotten that 
each individual skin, like its possessor, has its idiosyncrasies. A 
remedy that in a given type of the disease will commonly give 
prompt relief, may in others prove of no benefit and even aggravate 
the condition. An idiosyncrasy may exist forbidding the use of 
particular drugs, such as carbolic acid, glycerin, resorcin, etc., or it 
may prevent the employment of certain classes of applications, as, 
for example, ointments, powders, lotions, etc. The choice of reme- 
dies must further be influenced in each case by a consideration of the 
type or phase, severity, and duration of the disease, of the region and 
extent of surface involved, and of the age, occupation, and climatic 
and other surroundings of the patient. 

The general objects and principles of treatment in eczema may 
conveniently be grouped under the following heads: (1) exclusion 
of all sources of irritation to the skin; (2) relief from pruritus, 
burning, and other morbid sensations; (3) antiseptic dressing; (4) 
reduction of local congestion in acute, and stimulation of circulation 
in chronic, cases ; (5) repair of the horny layer in acute, and destruc- 
tion of the thickened and abnormally keratinized horny layer in 
chronic, forms of the disease. 

1. Exclusion of all Sources of Irritation. — This is one of 
the most important, the most varied, and often the most difficult and 
complex problems. Frequently a simple protective dressing is all 
that is required; more commonly the object is not so readily attained. 
Irritation of the skin due to its malnutrition or to conditions of ill 
health must be relieved in accordance with the principles of internal 
medicine, as has been indicated in discussing the internal treatment 
of eczema. 

The exclusion of all sources of irritation necessitates, secondly 
the avoidance of all injurious external contacts. Only gross ignor- 
ance or carelessness will overlook the fact that the inflamed skin. 



208 HYPEREMIAS AND INFLAMMATIONS. 

like the inflamed bone or the inflamed bladder, calls imperatively 
for rest. The prevalent idea, however, is that the patient with an 
inflamed joint retires to his couch or bed, while the patient with an 
eczema, if his disease be not so formidable as to necessitate temporary 
withdrawal from the pursuits of business or of pleasure, belongs 
always to the peripatetic class. He consults a physician, swallows 
some medicine, anoints his eczematous skin with a salve, and returns 
from necessity or from choice to the vocation in which his complaint 
was begotten. Such an one should distinctly understand that his 
recovery will be much slower and more uncertain than it would be 
with the rest and protection that every inflamed organ demands. 

Next is involved the exclusion of all topical irritants (in the 
hands of either physician or patient) designed to relieve the disorder, 
but having a precisely opposite effect. The number and variety of 
these medicaments are far from being commonly appreciated; some 
are useful in advanced stages of the disorder, and harmful in its 
earlier periods. These articles, which are generally ordered by 
persons with a limited experience in diseases of the skin, represent 
a long list of stimulating and astringent ointments. Some are em- 
ployed in sheer ignorance of their offects, as, for example, crude pet- 
roleum, strong acids and alkalies, silver nitrate, turpentine, and con- 
centrated solutions of corrosive sublimate, intended to "burn out" 
the disease. 

Lastly, the exclusion of all sources of irritation necessitates pro- 
tecting the involved surface from the excoriations and other trauma- 
tisms produced by scratching, rubbing, and excessive washing of the 
eczematous skin, and from exposure of the inflamed surface to the 
air. The various applications and protective dressings here serve 
their purpose, but in the case of adults some restraint to prevent rub- 
bing and scratching is also necessary; in the case of infants this re- 
straint may need to be enforced. Fixed dressings are often of great 
value in immobilizing a part, or in preventing friction, bruising, or 
other injury to the inflamed surface. A light elbow-splint to pre- 
vent flexion of the joint often is of service in keeping the fingers 
from the face. Most patients have to be repeatedly and forcibly im- 
pressed with the fact that a few minutes of scratching or rubbing, 
or one untimely washing of the inflamed surface, or its unnecessary 
exposure to the air may undo all that has been gained in several 
days of patient and successful treatment. 

The great importance of rest and freedom from irritation of all 
sorts in eczema is well illustrated by the newborn infant, whose sensi- 
tive skin early responds by an explosion of eczema to its first harsh 
acquaintance with the outer world. It is a fact of importance 
that no child is born into the world eczematous. While nutritive 
and other constitutional changes, consequent upon the assumption of 
extra-uterine life, undoubtedly have their influence, the difference 
between the child unborn and the child born is, as regards eczema, 
a difference chiefly of skin-protection and skin-exposure. The former 



ECZEMA. 209 

enjoys what White has aptly termed a "prolonged, placid, subaque- 
ous life." Anointed with unguent and immersed in its water-bath 
of grateful temperature, its skin cannot be fretted to produce an 
eczema. The child, abruptly and often rudely brought into contact 
with the outer world, may speedily exhibit the most formidable symp- 
toms of the disease. This point is worthy of especial emphasis be- 
cause of the wide diffusion of erroneous doctrines respecting the 
nature of eczema and the method of its management, and because of 
the mischief resulting from the too common aggravation of the malady 
in its earliest manifestations, due largely, on the part of both phy- 
sicians and laymen, to a lack of appreciation of the fact that an in- 
flamed skin needs rest and protection as much as does any other simi- 
larly affected organ of the body. 

2. Relief of Pruritus. — The itching, burning, and other sensa- 
tions which accompany eczema are usually largely or entirely allayed 
by the complete protection of the skin from irritation. Antipruritics 
are, however, frequently desirable and necessary. Among the best 
are carbolic acid, hydrocyanic acid, camphor, menthol, and salicylic 
acid, each in the strength of 0.5 to 2 per cent, (rarely stronger) in 
lotions, ointments, jellies, pastes, etc. Saturated solutions of boric 
acid, or the lead-and-opium wash, answer in many acute cases. If a 
remedy does not relieve the itching, it should be changed for one that 
will, unless the fault lies in the method of application. The most 
common error in the use of local remedies is found in the five- and ten- 
minute, or longer, intervals during which the skin is not protected, 
either as a matter of convenience or with a view to its appearance or 
as a result of carelessness in removing and reapplying the dressings. 
Exposure to the air for a few seconds only of an acutely inflamed 
surface may be sufficient to arouse a violent attack of itching or 
burning. The relief of pruritus by the use of drugs internally is 
considered under the head of internal medication. 

3. Antiseptic Dressing. — It is not known to what extent ec- 
zema may be due to, or may be modified by, the various micro- 
organisms that come in contact with the skin, but severe cases are un- 
doubtedly complicated and prolonged by the action of such bacteria, 
and it is well in every case, when possible, to prevent their activity. 
Simple protection does much to accomplish this end, while, fortu- 
nately, most of the remedies used as antipruritics are also more or 
less parasiticidal. In certain forms of the disease, such as seborrheal 
dermatitis, sulphur, resorcin, and other parasiticides are necessary. 

4. Relief of Local Congestion. — This is accomplished by posi- 
tion, compression, internal treatment, and largely by the removal 
of external irritation. Occasionally a direct astringent action may 
be obtained by the use of lead-water, lime-water, or by some of the 
rapidly drying jellies or glycerogelatin preparations. In chronic 
eczema passive congestion is removed by means of stimulating washes, 
soaps, ointments, etc. 

5. Repair of the Epidermis. — If the preceding indications are 
14 



210 HYPEREMIAS AND INFLAMMATIONS. 

fulfilled, repah* takes place naturally. It may be aided and hastened 
somewhat in suitable cases by the use of very mildly stimulating 
remedies, such as weak preparations of sulphur, resorcin, ichthyol, 
thiol, tar, etc. In chronic cases with much thickening of the epi- 
dermis the abnormally and imperfectly keratinized horny layer must 
be destroyed and removed before the process of repair can begin. 
For this purpose salicylic acid in ointment is especially valuable. 
Other remedies used for the purpose are tar, sulphur, resorcin, chry- 
sarobin, pyrogallol, etc. 

Local Treatment of Different Types and Phases of Eczema. 1. Acute 
and Subacute Eczema. — Tn selecting remedies for use on the acutely 
inflamed integument it is always best to begin with one that is mild 
and soothing, and to make the application to a small surface only, 
until it can be determined that the preparation will operate favorably 
in the case at hand. So greatly do individuals differ in their re- 
sponse to a given remedy that it is often well to order an alternative 
treatment in case the first does not prove satisfactory. A remedy 
that induces comfort and brings relief to the patient will usually do 
good, while one that irritates will almost invariably do harm. 

Ct/eansi\<; ok the Skin. — Tn acute eczema the inflamed skin 
rarely tolerates pure water. The surface sin Mild be washed as little as 
possible, often not at all and this without soap and with soft water or 
with water that has been softened by the addition of borax, soda, bran, 
oatmeal, gelatin, or other demuleent, as outlined in the description 
of baths in the chapter on General Therapeuties. Hot water thus 
prepared and applied either as a lotion, a bath, a fomentation, or by 
sponging (withoui rubbing), cleanses the part, is frequently grateful. 
and alleviates the itching. When employed otherwise than as a 
fomentation its use should immediately be followed, as soon as the 
part is carefully dried, by the medicament -elected for topical appli- 
cation. During the acute stages cleansing of the skin can usually 
be accomplished best by the use of olive- or other oil. For the re- 
moval of crusts and other accumulations a bland oil may be poured 
frequently over the surface with gentle inunction or be applied on 
lint or gauze. Even the oils, however, are at times sources of irrita- 
tion. They are made more soothing if combined with an equal part 
of liquor calcis to form a liniment. The addition of 1 per cent, of 
carbolic acid makes the mixture antipruritic and mildly antiseptic. 
In many cases the value of these applications for the removal of 
crusts is greatly enhanced by surrounding the whole with oiled silk 
or other impermeable tissue. Such dressing should not be applied 
continuously for many hours at a time for fear of macerating and 
weakening the skin. Flaxseed, starch, or other poultices may in ex- 
ceptional cases be applied for a few hours at a time to soften crusts 
and other accumulations on the surface. They should not be retained 
long enough to produce congestion and maceration of the skin. 

Powders. — Powders are useful in acute erythematous or papular 
eczema, in intertrigo, and occasionally in vesicular forms of the dis- 



3ij; 
3vj; 


8 
24 


q.s. 


q.s. 


3ij; 
3ij; 

3 ss ; 


8 

8 

16 


q.s. 


q.s. 



ECZEMA. 211 

ease. Applied to a discharging surface, powders tend to form co- 
herent crusts which retain secretions and are therefore irritating to 
the skin. In early stages when the discharge is slight, powders 
will sometimes succeed in wholly arresting the secretion. For this 
purpose they are of special value in mild forms of intertrigo. To 
prevent friction of underwear upon the skin the meshes may be 
tilled with a fine powder. In eczema of the hands the gloves may 
be treated in the same way. For absorptive purposes magnesium 
carbonate is effective. For use on dry surfaces zinc stearate, plain 
or combined with boric acid, salicylic acid, thiol, acetanilid, etc., is 
valuable on account of its lightness, and because it will adhere to any 
surface over which it is lightly rubbed with the hand. Among other 
excellent powders may be mentioned talcum, lycopodium, starch, 
rice-flour, bismuth subnitrate, zinc oxide, and calamin. The follow- 
ing formulae are good : 

]£ Acid, boric, 
Talc, 
01. ros., 

^ Acid, boric, 
Zinc, stearat., 
Talc, 
01. amygdal. amar., q.s. q.s. M. 

Anderson's powder and others containing camphor relieve pruritus 
better than the simpler powders, but are usually too stimulating and 
irritating for use in acute cases. In the preparation of dusting- 
powders it is of the utmost importance that they be made impalpable 
by sifting them carefully through silk bolting-cloth, as they are sources 
of irritation when they contain gritty particles. Only the best and 
finest grades of zinc oxide, talcum, calamin, and other powders should 
be employed, as many of the coarser grades found in the market can- 
not be rendered fine enough for use by any means at the command 
of the average chemist. 

Lotions. — Lotions are among the most valuable preparations 
in acute and subacute eczema, and in some of the chronic forms of the 
disease. They are especially useful in moist eczema, where it is 
necessary to protect the surface and relieve the itching, and at the 
same time to avoid the retention of secretions by the dressing. The 
chief drawback to the use of a lotion lies in the necessity of its fre- 
quent application to prevent drying. This objection may be removed 
partially by the addition of 2 per cent, or more of glycerin or of 
tragacanth-mucilage. The effect of a lotion is further prolonged by the 
addition of some impalpable and inert or astringent powder, such as 
talcum, zinc-oxide, bismuth-subnitrate, or calamin. The powder, 
temporarily held in suspension by shaking the lotion immediately be- 
fore each application, is left as a desposit upon the skin. A simi- 
lar but less uniformly diffused effect is produced by the use of 
a dusting-powder immediately after the application of the lotion. 



212 HYPEREMIAS AND INFLAMMATIONS. 

In moist eczemas a better method is to keep the lotion constantly 
applied on gauze or other material in the form of wet dressings. 
Great care must be exercised in the removal of such dressings 
after they have become dry, for fear of wounding the skin. An 
effective method is to put a single layer next the surface, which is 
removed but once or twice in twenty-four hours or only when soiled 
or stiffened by secretions, while a number of outer and thicker 
layers may be changed frequently in order to keep the dressing wet. 
Lotions may be sedative, astringent, or stimulating. Many and 
varied formulae are recommended, but a few only of the most useful 
and typical are given here, together with some suggestions as to their 
occasional modification. One of the most useful lotions, and one that 
is easily procured, is the following: 

IJ Acid, carbolic, 
Zinc, oxid., 
Glycerin., 
Liq. calcis, 

The quantity of any one or all of the first three ingredients may 
be increased or diminished as desired. Where carbolic acid does not 
act favorably dilute hydrocyanic acid may be substituted. The zinc 
may be replaced partially or wholly by one of the other powders 
mentioned above. Glycerin is needed, where carbolic acid is an 
ingredient, to increase the Bolubility of the latter drug in the aqueous 
solution: otherwise tragacanth-mucilage may be used instead of gly- 
cerin, or both may be omitted and half of the lime-water be replaced 
by an equal quantity of elder-flower water. By the use of one or 
more of these suggested changes may be formed several compound 
zinc-oxide lotions ; among the most desirable are : 







3U; 




2 






5j; 




4 






5u; 




8 


q.S. 


ad 


5 v »j ; 


q.8 


ad 240 



Acid, hydrocyan. dil., 3ss 5ij ; 2-8 1 

Zinc, oxi " 

Calamin. 

Liq. cak- 

Aq. sambuci, 



Zinc, oxid., ) _. ., 

\ :,:i 3j; 4| 

Liq. calcis. ) .. _. 10A . 

; \ aa 5 ,v ; l 20 l 



| M. 

$ Acid, carbolic. 3w-3ij; 2—81 

Bismuth, subnit, 3j i M 

Tragacanth., gr. xl ; 2|66 

Liq. calcis, q.s. ad 3vii j ; q.s. ad 240| M. 

Occasionally neither carbolic acid nor hydrocyanic acid has the 
desired antipruritic effect, even when increased in strength to 5 per 
cent., or both may be contraindicated for some reason. In such 
cases from 1 to 3 per cent, of menthol, camphor, or chloral may be 
added, with sufficient alcohol to hold them in solution. With these 
additions however, the lotion becomes more or less stimulating and 
must be used in acute cases with caution. 

The lead-and-opium wash is as useful as the various zinc oxide 
lotions, and in weeping cases with burning or hyperesthesia is usually 
more acceptable: 



ECZEMA. 213 

]£ Tinctur. opii, 5 SS 5 15 | 

Liquor, plumbi subacetat. dilut., q.s. ad Jviij > q.s. ad240| M. 

To this may be added, as in the case of the zinc oxide lotion, gly- 
cerin, boric acid to saturation, zinc oxide, or other powder to be left 
on the skin as a deposit, or from \ to 1 ounce (15. to 30.) of tincture 
of camphor if this is well tolerated and a more decided antipruritic 
effect is desired. 

A saturated solution of boric acid to which has been added 2 per 
cent, or more of glycerin or tragacanth-mucilage is an excellent appli- 
cation in moist eczema, and especially in suppurating forms. A 
weak solution of potassium permanganate is both antiseptic and 
antipruritic. Black wash, pure or diluted, is effectual in many 
moist forms of eczema, as are 1 to 10 per cent, solutions of ichthyol 
and thiol. Excellent lotions for soothing effect are made by adding 
1 to 2 drachms (4.-8.) of sodium bicarbonate or biborate to a quart 
(1000.) of thin oatmeal-gruel or of marshmallow-decoction. For a 
dry, irritable, and itching eczema, Boeck recommends the following: 



Tale., \ 

Amyli, / 


aa, ^ij; 


60 


Glycerin., 


3vj; 


24 


Liq. plumb, subacet. dil., 


3iv; 


120 



This is to be diluted with 2 parts of water, and applied with cotton 
or a brush. This lotion is decidedly cooling, but is not indicated in 
moist eczema. 

Any one of the zinc-oxide lotions described above may be com- 
bined with an equal quantity of almond-, olive-, or other oil to form 
a liniment. These combinations are especially good in acutely in- 
flamed surfaces of considerable extent, when it is desirable to avoid a 
drying effect. The popular carron oil, composed of equal parts of 
linseed oil and lime water, is often objectionable because of the ten- 
dency of the oil to dry and form a dense coating upon the skin to 
which it is applied. 

For subacute and indolent stages of eczema and for some acute 
cases, mildly stimulating and stronger antipruritic lotions containing 
tar, carbolic acid, menthol, camphor, chloral, and alcohol may be used. 
They should be tried cautiously and diluted at first. As a rule, they 
give best results when applied for a few moments several times a day, 
the part being kept covered in the interval with an ointment or other 
protective dressing. The following formulae, which may be modi- 
fied to suit individual cases, are to be recommended: 



M. 



M. 



Acid, carbolic, 
Glycerin., 
Menthol., 
Spirit, vin. rect., 
Aq. destill., 


3iss-3ss; 6-15 
3ij; 8 
3j-3ss; 4-15 
q.s.; 
q.s. ad ^viij ; q.s. ad 240 


Liq. picis alkalini, 

Glycerin., 

Aq. destill., 


3ss-3ij ; 2-8 

3ij; 8 

q.s. ad gviij ; q.s. ad 240 



214 HYPEREMIAS AND INFLAMMATIONS. 

Liquor carbonis detergens, or Duhring's compound tincture of 
coal tar (these preparations are described under Chronic Eczema) 
may be substituted for the liquor picis alkalinus. Hutchinson recom- 
mends the following in dry, subacute eczema: 

5. Liq. plumb, subacet., 3ss; 2 

Liq. carb. detergentis, 3ss; 2 

Aq. destill., q.s. ad ^viij ; q.s. ad 240 

Ointments. — Ointments are not, as a rule, well tolerated by an 
acutely inflamed skin, and are commonly more useful in subacute 
and chronic eczema, but there are many exceptions to the rule, and 
occasionally even an acute vesicular eczema is best relieved by use 
of an ointment. These should be properly and freshly prepared, and 
the debris of one dressing should be carefully removed before another 
application is made. Strata of an ointment, the older next the skin 
possibly rancid and having imprisoned beneath them pus or other 
products of disease, are a source of positive harm. In acute, and 
especially in weeping, eczemas an ointment is best applied by spread- 
ing it evenly on gauze, lint, or other soft material, which can then be 
laid upon the part. The salve-niuslhis devised by Tuna furnish an 
excellent substitute for ointments; they are clean and effective, and 
in every way admirable if they can be procured fresh. 

Among the best ointments for use on the acutely inflamed skin is 
the well-known diachylon ointment of Hebra. It is prepared as 
follows: to 11 ounces (420.) of the besl olive-oil are added 1 pound 
(480.) of water, and the whole heated to boiling on a w T ater-bath; 
3 ounces and 6 drachms (114. | of finely powdered litharge (oxide of 
lead) are sifted slowly into the liquid, which is then boiled and 
stirred constantly until all particles of litharge have disappeared and 
there is formed a perfectly homogeneous mass. During the cooking, 
water is occasionally added as required, and the whole evaporated to 
the desired consistence. The stirring is to be continued until the 
ointment is cold. While the mass is cooling 1 drop of oil of roses 
or of oil of lavender is added to each 2 ounces of ointment. When 
properly prepared the Hehra ointment is perfectly homogeneous, is 
of a light-yellowish color, and is of the consistency of butter. It is 
technically known as the "Unguentum diachyli albi" of Hebra. 
The simple ointment often becomes rancid in two or three weeks, 
but it may be preserved for months by the addition of 0.5 per cent, 
of carbolic acid or formalin. 

Duhring has modified this ointment as follows: 1 part of pure 
dry lead oxide is rubbed down with 1 part of water, and well mixed 
with 8 parts of the best olive-oil. The mixture is stirred for about 
two hours over a water-bath near the boiling-point, and is then cooled 
with constant stirring until the proper consistence is obtained. The 
ointment has been modified by PifTard also, and after him by Kaposi, 
in combining equal parts of lead-plaster and vaselin. It may be 
imitated fairly well by melting together 3 or 4 parts of olive-oil and 4 
of diachylon plaster, and stirring until cool. 



3j; 


4| 


SJJ 


301 


3iij; 


121 


q.s. 


q.s.| 



ECZEMA. 215 

The Hebra ointment, though useful often in full strength and 
even to the exclusion of other pomades, may often be combined with 
others with manifest advantage. Thus, 1 or 2 drachms (4.-8.) of it 
may be added to the ounce (30.) of lard, cold-cream salve, or cerate, 
with or without the addition of another drachm or two (4.-8.) of zinc 
oxide ointment. 

The official zinc-oxide ointment is an acceptable preparation in 
many acute cases ; equal parts of this and the Hebra ointment make 
an excellent combination. Any one of these ointments may be re- 
duced with from one to three times its volume of lanolin, vaselin, or 
cold-cream salve. The following formula gives an excellent soothing 
and protective ointment : 

]£ Bismuth, oxid., 
Vaselin., ) 
01. oliv., i 
Cerse alb., 
01. ros., 

Other bland and soothing ointments may be made by combining 
in various proportions cold-cream salve, lanolin, vaselin, lard, and 
simple cerate. The cerates are made sufficiently soft for gentle 
manipulation by adding 1 to 2 drachms (4.-8.) of glycerin or oil to 
each ounce (30.) of ointment, and they may be flavored with lavender, 
rosemary, or bergamot, as preferred. These simple bases may be 
stiffened and rendered somewhat astringent by the addition of from 
10 grains to a drachm (0.66 to 4.) or more of bismuth subnitrate or 
subcarbonate, zinc-oxide, or calamin to the ounce (30.). A very 
thin base may be prepared by mixing equal parts of lanolin, olive-oil, 
and glycerin. This is especially valuable for use on hairy surfaces. 
A creamy and cooling base is IJnna's " refringent ointment," which 
contains lanolin, 10 ; lard 20, and rose-water, from 30 to 60 parts. 
Any of the above bases may be medicated as desired; the most 
frequent addition being from 5 to 10 grains (0.33-0.66) of carbolic, 
boric, or salicylic acid, or a similar quantity of calomel or white pre- 
cipitate to the ounce (30.) of salve. With these unguents may be 
named glycerole of starch, cucumber ointment, emulsion of sweet 
almonds, decoction of Irish moss, and Hardy's formula— 2 parts of 
zinc-oxide, 8 of glycerin, 30 of cold-cream salve, and 15 drops of 
tincture of benzoin. 

The oleate of bismuth or of zinc is prepared by rubbing up 1 
drachm (4.) of the oxide of either metal with 8 (30.) drachms of 
oleic acid, and allowing the mixture to stand for two hours. It is 
afterward heated on a water-bath, where 10 drachms (40.) of vaselin 
and 3 (12.) of wax are dissolved in it, and the whole stirred until 
cold. This ointment is especially useful when employed in papular 
forms of eczema. In pustular eczema ointments containing iodo- 
form, boric acid, iodol, aristol, or europhen are indicated. 

The Combined use of Lotions and Ointments will often 



216 HYPEREMIAS AND INFLAMMATIONS. 

give good results. The black wash as recommended by Duhring, 
White, and others is often effective in acute vesicular eczema. 
The part is bathed for fifteen or twenty minutes two or three times 
a day with the wash, the sediment allowed to remain on the skin, 
and the whole covered with a piece of gauze or soft cloth on which 
has been spread a thick layer of zinc-oxide or other simple ointment. 
The lead-water or the zinc-oxide lotions may be used in the same way 
with simple ointments or pastes. 

Pastes. — Pastes are especially valuable in subacute eczema, and 
are often tolerated in acute forms better than an ointment. A thick 
paste is rarely indicated in moist eczema, as it prevents escape of the 
discharge from the surface. Pastes are more cleanly and adhesive, 
furnish better protection, are more drying, and require less frequent 
applications than ointments. They are formed by combining a sim- 
ple powder, usually insoluble, with an ointment-base, the proportions 
of the two being so adjusted as to produce a more or less stiff, some- 
what tenacious, mixture which may be spread as a protective covering 
directly upon the skin. The following paste recommended by Lassar 
may be taken as a type: 

5 Amyl., 3ijj 8 

Zinc, oxiil., 5ij ; 8 

Vaselin., 3 s * ; 15 

The substitution of talc for the starch in the above gives a paste 
with less tendency to concrete in Lumps on the skin. Boric acid used 
in place of the starch, produces a -till' and adherent paste. A 
very smooth and pleasant combination, and one thai is also fairly 
still' ;in<l adherent, is made of equal parts of talc, zinc-oxide, vaselin, 
and lanolin. These pastes serve as bases to which various medica- 
ments may be added. Those mosl commonly used in acute and 
subacute eczema contain boric, salicylic, and carbolic acids, in the 
strength of from 1 to 5 per cent. ; calomel, white precipitate, ichthyol, 
and thiol in similar proportions. Other remedies may be employed 
according to the indications. The following is an adherent and dry- 
ing paste : 

]£ Lanolin., 
Paraffin., 
Cerae alb., 
Aq. destill., gj 30 M. 

The lanolin, paraffin, and wax are thoroughly mixed before the 
water is added. A good drying and soothing paste, recommended by 
Morris, is made of equal parts of almond- or olive-oil, lime-water, 
and zinc-oxide. Unna recommends a paste prepared by mixing 1 
ounce (30.) of zinc-oxide with 2 ounces (60.) each of glycerin and 
an official mucilage. To either of these pastes may be added 1 per 
cent, of carbolic or salicylic acid. Other good bases are found in 
Elliot's bassorin-paste, 1 or Unna's gelanthum, both of which are de- 
scribed in the chapter on General Therapeutics. 

1 J. C. !>., 1S91, ix., p. 48, and 1892, x., p. 184. 



3i.i; 


60 


53; 


30 


5j; 


4 


53 J 


30 



ECZEMA. 217 

Glycogelatins. — These render excellent service in all dry forms 
of eczema, in which simply protection is required. Certain remedies 
may also be incorporated, such as 1 or 2 per cent, of ichthyol or 
thiol. A convenient formula is the following: 



} 



S; 


30 




45 
90 


3ijss; 
5v; 

S; 

3x; 


10 
20 
30 
40 



]£ Gelatin, alb. 
Zinc, oxid., 
Glycerin., 
Aq. destilL, B 11 ^ 90 l M - 

I£ Gelatin, alb.. 
Zinc, oxid., 
Glycerin., 
Aq. destill., 3x; 40 M. 

The ingredients are mixed on a hot water-bath and when cool 
and solidified may be cut in pieces of convenient size for use. Before 
application a sufficient quantity is melted in a dish placed in a 
receptacle containing water which is heated to a suitable degree; 
the liquefied material is then applied with a brush, care being taken 
that it is not uncomfortably hot for the patient. It dries somewhat 
slowly and rt is well after two or three minutes to pat the surface with 
cotton or to cover it completely with gauze. By increasing the quan- 
tity of glycerin a softer and more slowly drying preparation is 
formed. By lessening the quantity of glycerin and increasing that 
of the zinc-oxide or gelatin a firmer and more rapidly drying product 
is obtained. Though these glycogelatins serve their best purpose in 
the dry forms of the disease, there are few forms of eczema in which 
they may not at times be used with benefit. 

In subacute and indolent types Pick's Gelatin Sublimate is 
useful. This is prepared by mixing 30 grammes (§i) of gelatin with 
sufficient water to liquefy it on a water-bath, and evaporating to 75 
grammes (§ijss) ; 25 grammes (3yj) of glycerin and 5 centigrammes 
(gr. f ) of corrosive sublimate are then added. The product must 
be melted before applying. 

In acute erythematous eczema Pick's Teagacanth Vaenish 
("linimentum exsiccans") is a very acceptable remedy in that it is 
easily applied without heating, dries quickly, is clean, and distinctly 
cooling. It is composed of tragacanth, 5 ; glycerin, 2 ; and boiling 
water, 93 parts. To this may be added from \ to 2 per cent, of boric 
or carbolic acid, or from 2 to 5 per cent, of some simple powder, such 
as zinc-oxide. The tragacanth must be soaked for several hours in 
a part of the water and thoroughly triturated before the other ingred- 
ients are added. Stelwagon 1 prefers a varnish containing zinc oxide, 
2 parts ; glycerin, 1 part ; and mucilage of acacia, 5 to 8 parts, as it 
dries quicker than the tragacanth preparation. 

Subacute Eczema. — Attention has already been called to the fact 
that no sharp line can be drawn between acute, subacute, and chronic 

1 Diseases of the Skin, 5th ed., p. 289. 



218 HYPEREMIAS AND INFLAMMATIONS. 

eczema, the degree of inflammation in any given case varying from 
time to time. Most acute cases, however, are followed by a longer 
or shorter period of subacute or chronic inflammation. In propor- 
tion as the disease progresses to the subacute or chronic stage the 
various topical medicaments employed may be changed in character 
so as to produce an astringent or stimulating effect upon the part. 
The utmost skill and prudence, however, are needed at this juncture, 
and changes should be made cautiously, for it is at this time that the 
disorder is readily awakened to renewed activity, a turn of affairs 
which is especially annoying to the patient, and particularly so to the 
practitioner if there be a suspicion (often too well founded) that the 
aggravation has been due to the treatment. 

Again, many cases of eczema are subacute and indolent from the 
beginning, yet are liable at any time to present acute manifestations; 
consequently in beginning the treatment of an apparently subacute 
case it is well to use mild measures first, gradually changing to those 
stronger and more stimulating. 

The treatment of subacute eczema varies from that of the acute 
type chiefly in demanding more stimulating remedies and those hav- 
ing a greater antipruritic effect. For this purpose many of the sub- 
stances already recommended for acute eczema may be employed, 
but in increased strength. Tn this phase of the disorder pastes are 
especially valuable, as are also the glycogelatins, though occasionally 
lotions and powders produce the best results. On the other band. 
cases occur in which ointments make the best applications. When 
milder measures will no1 succeed in a given case the stronger remedies 
recommended for chronic eczema should be employed. 

Chronic Eczema. — The general principles of local treatment of 
chronic eczema are those of the acute form of the disease except that 
stronger and more stimulating remedies are used. It must be remem- 
bered that many chronic eczemas are subject to acute exacerbations, 
when milder and BOOthing treatment must be adopted for a time. 
Moreover, chronic eczema appears in such varied phases in different 
individuals, and in the same individual in successive attacks, that it is 
impossible to select certain formula' and declare that these will be of 
benefit in a given type of the disease. It is only by careful observa- 
tion of the general principles and objects of the treatment of eczema, 
discussed in the preceding pages, that the varied conditions can be 
successfully treated. 

Cleaxsixg of the Skix. — This should be accomplished accord- 
ing to directions already given, by means of oils or liniments, though 
in chronic eczema more vigorous measures can frequently be em- 
ployed, including the occasional use of soap and water, some densely 
infiltrated patches tolerating and even being benefited by a daily wash- 
ing. For this purpose a good toilet-soap, or, when the skin will 
permit, tincture of green soap, may be used. The Sarg glycerin 
soap is an admirable substitute for these articles when the skin is 



ECZEMA. 219 

tender and where an elegant toilet-preparation can be ordered. The 
crusts and scales once removed, subsequent topical applications can 
be made as required in each case. 

Powders. — Powders are useful in chronic as in acute eczema 
for mechanical protection, to prevent friction between apposed skin- 
surfaces or between the skin and clothing. They are often of value 
when dusted and patted over a paste, thus making a thicker and 
more cleanly dressing, and one less likely than a paste to be rubbed 
off. The Anderson and other antipruritic powders are frequently 
serviceable for application during the day, when other dressings 
cannot well be employed on account of the patient's occupation. 

Lotions. — Lotions are of less value than in acute eczema, but are 
often useful for temporary purposes after the skin has been unduly 
irritated by other dressings. Stimulating lotions or solutions are 
sometimes painted on the skin and allowed to dry, or are used for a 
few minutes each day, the surface in the intervals being covered with 
an ointment. 

Ointments. — Ointments are the preparations most used, espe- 
cially in the dry, scaling forms of the disease, in which penetration of 
the remedy is desired. To serve this end, they should be gently 
rubbed into the surface, which is later covered with more of the same 
ointment spread on gauze or a soft cloth. 

Pastes. — Pastes often answer better than ointments, especially 
when protection and drying of the surface are the chief objects of 
treatment. In combination with powders, as described above, they 
furnish convenient and effectual applications in most cases of chronic 
eczema. In many dry forms of the disease either plain or medi- 
cated Gly co gelatins furnish the best application. They are of special 
value in dispensary and other cases in which the physician does not 
wish to entrust the dressing to the patient, as a gelatin-dressing may 
often be left in place for several days or a week. For the applica- 
tion of tar, chrysarobin, salicylic acid, and a few other remedies to 
small areas, Collodion and Fluid Gutta-percha (Traumaticin) form 
convenient and cleanly vehicles. 

Applications in chronic eczema, as a rule, should be more antipru- 
ritic and more stimulating than in acute and subacute phases of the 
disease. The remedies recommended above may be used in increased 
strength. This is especially true of the drugs classed as antipruritics, 
such as carbolic acid, creosote, camphor, menthol, and chloral. 

Salicylic acid is one of the most useful remedies in chronic eczema. 
It is antipruritic and is effective in destroying thickened areas 
of dry horny epidermis. It may be incorporated in the strength 
of from 2 to 10 or even 20 per cent., in most of the ointments, pastes, 
and plasters recommended in the preceding pages. In the glyco- 
gelatins more than 2 or 3 per cent, cannot be used without the addi- 
tion of a fat, preferably 5 per cent, of fresh lard. For small areas 
of infiltration with marked thickening of the horny layer salicylic 



220 STPEBJEMIAS AND INFLAMMATIONS. 

acid is best used with Duhring's modifications of Pick's " salicylated 
soap plaster." The acid has a tendency to soften the plaster if em- 
ployed in strength above 5 per cent. The formulae are as follows : 

5 Emplast. saponis (U. S. P.) liquefact., ^iij ; 90 

Olei olivas opt., f 5ij ; 8 

Acid, salieyliei, 3ss; 2 

For a 5 per cent, plaster: 

# Emplast. saponis (U. S. P.), 3 j ; 30" 
Olei olivae, nTxxiv; l|60 
Acid, salieyliei, gr. xxiv; 1|60 M. 

For a 10 per cent, plaster : 

I£ Emplast. saponis (U. S. P.) liquefact., 5J ; 30j 

Acid, salieyliei, gr. xlv; 3| M. 

For a 20 per cent, plaster : 

# Emplast. plumbi (U. S. P.), gj; 301 
Cerae flavse, K r - xlv ; 3| 
Acid, salieyliei, gr. xc; 6| M. 

Plasters made according to the above formulae are adhesive, and 
are firm enough to be moulded and kept in rolls. For large surfaces 
they should be warmed before applying to make them spread easily. 
Resorcin and other remedies may be substituted for salicylic acid, 
but resorcin has a tendency to stiffen the plaster and requires the ad- 
dition of oil. Tuna's Balicylated gutta-percha plaster-mulls make 
excellent substitutes for the above, but to be serviceable they should 
always be fresh. 

Tab.— This is one of the most valuable remedies, when tolerated 
by the skin, for the treatment of chmuic eczema. The preparations 
mosl commonly employed are pix liquids (pine-tar), oleum rusci 
(oil of white birch), oleum cadinum (oil of cade), and terebinthina 
Canadensis (balsam of fir). Oil of cade, as found in most of the 
shops, is inferior to oleum rusci. The tars are best applied in the 
form of ointments, but are occasionally painted over the affected 
surface in a liquid state with a camel's-hair brush. From \ to 2 
drachms (2.-8.) of tar, in combination with a suitable quantity of 
potassium subcarbonate, are sufficient to add to 1 ounce (30.) of 
ointment, the proportions suggested being varied to suit the require- 
ments of each case. 

In beginning the use of tar with any individual, weak prepara- 
tions should first be employed, and the strength be gradually in- 
creased until tolerance of the skin is determined, as an acute derma- 
titis not infrequently follows the application of stronger preparations. 
A convenient method is to order one jar of a fairly strong tar oint- 
ment, and another of the zinc-oxide, the Hebra, or other simple salve. 
Before the first application the patient takes a sufficient quantity of 
the simple ointment and mixes with it a very small proportion of the 
tarry preparation. If no irritation follows this application, the 
amount of tar can be gradually increased with each dressing until 



3ss-3ii j ; 


2-12 


3j-3ss; 


1.33-2 


S; 


30 



ECZEMA. 221 

enough is used to relieve the itching and to reduce the infiltration, 
after which a simple paste or powder may be employed until the skin 
has regained its normal strength and resistance. If the application 
at any time causes an acute dermatitis, simpler remedies for a time 
must be substituted. To accomplish the best results, tar ointments 
should be rubbed well into the skin or liquid preparations painted 
on. Sometimes it is well to permit the application to accumulate 
until thrown off by exfoliation, but it is better to cleanse the skin with 
oil or with soap and water, according to indications, before each ap- 
plication. 

The following formulae are illustrations of the manner of com- 
pounding the various preparations of tar : 

~fy 01. rusci (vel cadini), 

Potass, bicarbonat., 

Unguent, aq. ros., 
Ft. ungt. 

For the potassium bicarbonate -J to 1 drachm (2.-4.) of zinc- 
oxide may be substituted, or from 2 to 4 grains (0.133-0.266) of red 
mercuric oxide, or yet -J scruple (0.66) of mild chloride. The 
vehicle, also, of such ointments may be vaselin, lanolin, simple cerate, 
or \ ounce (15.) of either in combination with an equal quantity of 
diachylon ointment. 

Of fluid preparations may be mentioned alcoholic solutions of tar, 
\ ounce (15.) of the latter to the pint (500.) of alcohol; and in cases 
in which the detersive action of soap is also needed sapo viridis may 
be added as follows : 

I£ Picis liquids, f^j-Sij 5 30-60 

Sapon. virid., f^jss-Jiij; 45-90 

Glycerin., fjj ; 30 

Spt. vin. rectif ., f Jviij ; 240 

01. rosmarin., f3ss; 2 M. 

Sig. — To. be rubbed gently into the skin with a flannel rag. 

Bulkley devised an alkaline solution of tar and caustic potash, 
which is especially serviceable, as it is miscible with water in all pro- 
portions. It is constituted as follows : 

# Picis liquids, f^ij; 601 

Potassse caustics, gj; 30 

Aq. destillat., gv; 150 1 M. 

Dissolve the potash in the water, and add slowly to the tar in a mortar 
with friction. 

Sig. — "Liquor picis alkalinus." To be used diluted as a lotion. 

Of this solution 1 drachm (4.) or more may be added to a pint 
(500.) of water. For an ointment, the same quantity of the solution 
may be added to the ounce (30.) of cold-cream salve, lanolin, or 
vaselin. It should be remembered, however, that the caustic alkali 
renders this preparation exceedingly irritating to a sensitive skin, and 
it should be employed with caution upon any untested surface. 



222 HYPEREMIAS AND INFLAMMATIONS. 

An excellent fluid preparation is Duhring's "compound tincture 
of coal-tar," prepared according to the following formula : " Coal-tar 
(1 part) should be digested with tincture of quillaja (6 parts), with 
frequent agitation for not less than eight days, preferably for a longer 
period, and finally filtered. The resultant product is a brown-black 
tincture which, upon the addition of water, forms a cleanly yellowish 
emulsion, the color and certain other characters varying with the 
variety of coal-tar used. The strength of the tincture of quillaja 
should be 1 to 4 with 95 per cent, alcohol." Five to fifteen minims 
to the ounce (0.33-1. to 30.) of water is the strength recommended 
for use. 

The formula recommended by Spender, and described in the 
chapter on General Therapeutics, is a useful means of testing the 
efficacy of tar upon an eczematoua surface. Olive-oil or cod-liver oil 
may be combined with equal parts of one of the tarry preparations 
and rubbed into the eczematoua skin. When fluid or semifluid com- 
pounds of tar are needed upon the scalp 1 drachm (4.) of the article 
selected may be rubbed up with an equal quantity of glycerin and 
added to 6 ounces of cologne-water ( 180.). Creolin is very similar 
in its action to tar and is miscible with water. 

Hebra disclaimed any special value for sulphur in eczemas un- 
complicated by the aearus scabiei, but in Wilkinson's and other oint- 
ments it serves a good purpose. The following formula supplies an 
ointment rather less severe that has practical efficacy in chronic 
eczema : 

120 
30 
15 



I£ Picis liquid, (vel. ol. rusci), 


3iv 


Adipis, 


5.i 


Ol. oliv.r, 




Misce et adde: 




Terebinth. Canadens., \ 
Sulphur, flor., / 




aa 5.1 ; 



30 1 



M. 



Sig. — To be applied three limes daily with a soft brush. 



To this formula may be added green soap if a stronger effeci ifl 
desired. 

Ointments and pastes containing 10 to 30 grains (0.66-2.) of 
sulphur, and 5 to 15 grains (0.33 to 1.) of salicylic acid in similar 
proportions often give good results in circumscribed, infiltrated 
patches of eczema which show tendencies to occasional moisture and 
crusting. Ointments containing from 1 to 4 per cent, of sulphur 
favor keratoplasia. 

Ichthyol and thiol, in ointments of the strength of 10 per cent. 
and less, or in aqueous lotions containing from 5 to 50 per cent, of the 
drug, are useful in localized patches of the disease, especially of the 
papular and scaling varieties. Ammonium ichthyolsulphonate is pref- 
erable to the sodium compound. Its influence upon the skin seems 
to resemble both that of the tars and of chrysarobin. Unna's varnish 
containing ichthyol is convenient, as it dries rapidly and is easily re- 



ECZEMA. 223 

moved by washing. It is prepared as follows : 40 parts of starch are 
mixed with 100 parts of water, to which are added 40 parts of ich- 
thyol; after thorough trituration there are added 1^ parts of a con- 
centrated solution of albumin which should be prepared at a tempera- 
ture low enough to prevent coagulation. 

Other remedies which may be added to ointments, pastes, or plas- 
ters in strength varying from 1 to 10 per cent, for the treatment of 
chronic eczema are : resorcin, chrysarobin, pyrogallol, calomel, and 
white precipitate. Occasionally systemic intoxication has followed 
the use of these remedies over large surfaces, and they are adapted 
best to employment on small areas. The three first named stain the 
skin and clothing. Other preparations of mercury may be employed 
with advantage in some cases. 

In persistent areas with marked infiltration of the skin radio- 
therapy often gives excellent results. We have found it of value most 
frequently in the dry scaling forms of the disease, but it is indicated 
also in moist forms with infiltration, and especially in cases in 
which suppuration is present. The technique is the same as that 
recommended for psoriasis. 

An effective method of treating circumscribed thickened patches 
of eczema is the following : a piece of green soap as large as a walnut 
is spread upon a flannel rag, and rubbed into the eczematous part for 
several minutes, pressing firmly the while, and from time to time dip- 
ping it into water in order to produce lather. The duration and firm- 
ness of the rubbing depend chiefly upon the amount of infiltration 
present, but to some extent upon the general condition of the skin. 
The production of an acute dermatitis by too severe treatment should t 
be avoided. Following the soap-rubbing the part is washed free from 
suds with water, carefully dried, and the oil or ointment selected for 
topical use immediately applied on strips of muslin, which are neatly 
bandaged to the part. Hebra's diachylon ointment is one of the best 
for this purpose. The soap must be rubbed in at least twice every 
day, so Jong as any excoriated points appear after its application. 
Soap rubbed into the healthy skin will not be followed by such effects, 
the part feeling clean, smooth, and comfortable after it has been 
washed. The contrast this offers to the eczematous patch is very strik- 
ing, the latter representing numerous intensely red, raw, and moist 
spots. The appearance of these red, shining, moist points after the 
first inunction suggests to the inexperienced eye that the malady has 
been aggravated ; but they become fewer in number after each appli- 
cation, and finally disappear, the eczematous surface being then no 
more affected by the soft soap than is the surrounding healthy skin. 

Many circumscribed patches of chronic eczema are greatly bene- 
fited by daily painting with a saturated solution of pyoktanin-blue. 
It is usually unproductive of pain, and, as it forms a thin film over 
the surface to which it is applied, probably serves a good purpose for 
the time being by the exclusion of air. It acts also as a parasiticide. 
The chief objection to its employment lies in the staining it produces 



224 HYPEREMIAS AND INFLAMMATIONS. 

not only of the skin, but also of all articles brought into contact 
with it. 

Among the more severe measures occasionally employed for small 
patches of eczema which resist milder treatment may be named : can- 
tharides employed as a blister, silver nitrate in crayon or in solution, 
from 3 to 60 grains to the ounce (0.20-4. to 30.), and iodine in com- 
bination with carbolic acid. The following formula should furnish a 
clear vinous-red fluid, which may be applied pure or in dilution: 



I£ Iodin. tinct.. 


3ss; 


21 


Acid, carbolic, (cryst.), 


5j; 


4 I 


Glycerin., 1 
Alcoholis, J 


aa 5ij; 


aa. 8| 


Aq. destillat., 


ad f'5J; 


ad 30 1 


Sig. Iodized solution of carbolic acid. 







111 cases in which there is considerable pruritus, especially in ob- 
stinate patches of papular eczema, the iodized phenol of Bellamy may 
be substituted for the above. The formula is: 

S Acid.carbol.,1 n - 5j .-- 4| 

Iodini cryst., i •" 

Combine with gentle heal and add an equal part of glycerin. 
Sig. Iodized phenol; to be applied twice daily with a glass rod. 

Prognosis. — Eczema is an entirely curable disease, but uncer- 
tainty attends its prognosis as regards the duration of an attack and 
the probability of a relapse. AVith respect to the questions mosl fre- 
quently asked, those relating to contagion, heredity, and persistenl 
.lesion- relics, a favorable response can be made; but the fact remains 
that some forms of the disease are insignificant, xnne persistent, and 
some particularly liable to recurrence from very slighl provocation. 
Only after careful weighing of all the conditions exhibited by the 
skin and by the other organs can a reasonable probability as to the 
future of the disease be estimated. Eczema is a disease exceedingly 
common, and one subject to aggravation by causes well-nigh innu- 
merable. Were the physician always in position absolutely to insure 
his patient a proper mode of living, and the exclusion of all sources of 
irritation of the skin, the prognosis would be much more satisfactory. 
In hospital-patients, over whom such control is more perfectly at- 
tained, the results of treatment may be predicted with some con- 
fidence. 

In general, it may be said that acute eczema is more readily re- 
lieved by proper treatment than are the chronic forms of the dis- 
ease; that eczema with a discoverable cause is more manageable 
than one the etiology of which is obscure : that eczema of the very 
young and of the very old is at times particularly rebellious ; that the 
non-discharging phases of the disease are rather more persistent than 
those accompanied by secretion ; that eczema lingering at the mucous 
outlets of the body (auditory canal, nostrils, mouth, nipple, anus, 
vagina) is more obstinate than when it affects the skin of other parts 



ECZEMA. 225 

(shoulder, neck, lumbar region) ; that eczema with constant aggrava- 
tion or complications (fissure of skin of hand, varicose veins of leg, 
apparatus for anchylosis) is more stubborn in proportion as these com- 
plications or aggravations cannot, from the circumstances of each case, 
be set aside; and, finally, that an eczema which has long existed, or 
has repeatedly recurred, as, for example, with every season of ex- 
tremely cold or hot weather, is, after relief, very liable to return. The 
parasitic eczemas are particularly amenable to treatment. 

TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 

Eczema of Children, — Inflammation of the skin in infants and 
young children is usually acute in type, owing to the delicate structure 
of the skin and to the tendency in childhood to acute rather than sub- 
acute and chronic pathological changes in the various organs of the 
body ; consequently the eczema of infants is commonly vesicular, pus- 
tular, or vesiculo-pustular in expression. Though acute in type, 
eczema of young children is frequently chronic in duration; a child 
for example of two, three, or four years of age may have had the 
disease in varying degrees and extent since a few weeks after its birth. 
In these persistent cases there may be considerable thickening and in- 
filtration of the skin, and periods during which the symptoms are 
those of a subacute or chronic process ; but acute manifestations recur 
at frequent intervals and usually predominate. 

The causes peculiar to eczema of childhood are found in the ease 
and frequency with which the delicate skin is injured by external 
agents, such as soap, hard water, rough clothing, dirt, pathological 
secretions, etc., together with the rubbing and scratching that follow 
pruritus from any cause ; in the presence of toxines in the blood, re- 
sulting from deficient elimination or from imperfect metabolism and 
assimilation of food, due commonly to improper or irregular feeding, 
and from various systemic diseases ; in the so-called reflex irritation 
arising from dentition; and in the local infections of the skin with 
pus-cocci and probably at times with other micro-organisms. 1 Accord- 
ing to statistics gathered by Crocker, more than one-third of all cases 
of eczema in children begin during the first year of life. 

Treatment. — Success in the treatment of these young patients de- 
pends, first upon the painstaking search for, and removal of, the 
causes; and secondly, upon the care with which the principles of 
treatment of acute eczema, already set forth, are carried out in all 
details. Special attention should be given the question of diet and 
every effort should be made to prevent anto-intoxication of intestinal 
origin. In the local treatment gentle measures should be the rule. 
The theory that systemic injury and even death may result from a 
too vigorous treatment of infantile eczema is advocated by a number 
of observers. 2 Post mortem examinations made in lethal cases have 

1 Cf. Hall, B. J. D., 1905, 17, Nos. 5, 6, 7 and 8, and ibid., 1908, 20, pp. 4-11. 

2 Cf. Key, Centralblatt fur Kinderheilkunde, 1902, ref . Archiv, 1904, lxviii., p. 
309, and Korrespond. fur Schweitzer Aerzte, 1904, No. 1, ref. in Archiv, 1905. 
hqriv., p. 126, 



226 E.YPEKMMIAS AND INFLAMMATIONS. 

shown death to have been due in some instances to a status lymphati- 
cus, in others to cardiac degeneration probably arising from the pro- 
longed absorption of toxines from the eczematous surface. 

Eczema of the Scalp (Eczema Capitis, Eczema Capillitii). — 
When the scalp is affected with eczema the symptoms differ somewhat 
according to the age of the patient. In adults the erythematous and 
squamous varieties of the disease are more common ; in infants and 
children the pustular variety. In the former the eruption is usually 
circumscribed and in patches; in the latter it is more diffused. In 
the same proportion, also, the former is generally asymmetrically and 
the latter symmetrically developed. 

In infants and children the pustules rupture early and their con- 
tents dry into dirty-whitish, yellowish, or greenish crusts, matting the 
hairs, thus serving as foci for dust-accumulation and as nests for lice, 
the crusts being superimposed upon a reddish, oozing, pus-covered, or 
occasionally indolent skin, often foul-smelling, and usually compli- 
cated by a seborrhea. The so-called "milk-crust" is usually a com- 
pound of dried pus and altered sebum. The itching is not so intense 
as in some other forms of the disease. Post-cervical, pre-auricular, 
and occipital adenopathy are common, and in strumous children sup- 
puration of the affected glands may occur. The causes of this form 
of disease are evidently associated with local conditions. The rapidly 
growing hairs of the scalp are in intimate association with the numer- 
ous and large sebaceous glands of the same part, which at times un- 
questionably respond by an exudative process when a relatively slight 
external irritation is added to the physiological stimulus they feel. 
Such local irritants are often not wanting to push the disturbed 
equilibrium into the scale of disease. White calls attention to the 
common neglect in removing the " pre-natal cap of cheesy material " 
as well as to rude and unskilful attempts to accomplish the same end. 
Extremes of temperature, friction, excess, neglect, and absence of 
endeavor to wash the scalp, all these contribute to originate or to 
aggravate the disorder. 

The affection when complicated or induced by lice is more com- 
mon in children than in infants, doubtless in consequence of the 
greater independence of the former and their gregarious habits. In 
girls with relatively long hair the ova, or nits, of the parasite are 
readily distinguished, adhering closely to the hairs, and accumulated 
especially about the occipital region. The itching is usually more 
annoying than in pustular eczema not thus complicated. 

The erythematous and squamous forms of the disease, rather more 
common in adults, originate frequently in seborrhea when scratching 
has been practised or irritant applications have been made. The 
eruption here usually occurs in asymmetrical patches, or it may be 
limited to a single patch tolerably well defined in outline, often upon 
one side of the scalp, not, as in infancy, preferring the vertex. 

The diagnosis of these forms of disease has been already consid- 
ered. The disorders most commonly confused with eczema of the 
scalp are psoriasis, seborrhcea, tinea favosa, and tinea tonsurans, 



TOPICAL AND SPECIAL VABIETIES OF ECZEMA. 227 

Treatment.. — In the treatment of eczema of the scalp in infants and 
children the first indication to be met is the removal of the accumu- 
lated crusts. When this removal is harshly accomplished it becomes 
a fruitful source of further mischief; it is, therefore, necessary to 
proceed with great gentleness. The thorough softening of the crusts 
is all-important. For this purpose it is necessary to soak them with 
oil and to retain this substance in intimate contact with the scalp. 
Olive- or cod-liver oil may be selected, and, if needful to correct the 
odor or for other purpose, 1 drachm (4.) of carbolic acid may be 
added to each pint (500.), with 2 drachms (8.) of the balsam of 
Peru. A neat-fitting skull-cap, constructed of suitable impervious 
material, should then be applied smoothly, and fastened in place by 
a light bandage, never by elastic-rubber bands. After several hours 
of soaking the crusts should be removed with warm water and spirit- 
of-soap washing, and the entire process be repeated until the crusts 
are completely detached. In selecting an article for subsequent med- 
ication of the scalp it should be remembered that even infantile ec- 
zema will proceed to a natural involution if unirritated ; hence 
oleated lime-water, or oil of sweet almonds alone, will often answer 
better than an ointment, and, even where there is considerable 
acuity of the inflammatory process, lime-water alone, with possibly a 
small quantity of glycerin added, will be effective. As the discharge 
and crusting cease ointments instead of oils and lotions may be em- 
ployed. The ointment is to be rubbed gently over the surface with 
the tip of the finger, and the skin afterward protected with suitable 
dressing, such as a gauze-cap. Good ointment-bases for use on the 
scalp are lanolin, vaselin, equal parts of lanolin and oil, or equal 
parts of glycerin, lanolin, and oil. The following remedies may be 
incorporated in strength varying from 1 to 5 per cent. : carbolic, sali- 
cylic, and boric acids; calomel, white precipitate, ichthyol, sulphur, 
resorcin, and tar. In children and in acute cases strong prepara- 
tions must not be used. When the seborrhoeal element is at all pro- 
nounced the treatment is that of seborrhoeal dermatitis. 

It is rarely needful to cut the hair unless nits be found, though in 
public charities it is a more expeditious method of arriving at the 
end when a nurse has to dress the heads of several children in a 
single ward. Lice when present may be destroyed by the applica- 
tion of petroleum, bichloride lotions, or alcohol. The nits are re- 
moved with dilute acetic acid, alcohol, or cologne-water from hairs 
which it is not desirable to cut. In adults, especially in women, the 
hair should be spared, while the patient is warned that the loss of the 
growth upon the scalp may be considerable. Where an obstinate 
seborrhoea is followed by eczema the latter may be succeeded by alo- 
pecia ; in the absence of seborrhoea the hairs usually are reproduced. 
It is rarely necessary to employ the skull-cap in adults, since one can 
succeed in insuring the necessary applications by directing the atten- 
tion of the patient to the necessity of care and thoroughness. 

As the disease in both classes of patients advances to a subacute 



228 HYPERMMIAS AND INFLAMMATIONS. 

or chronic stage the treatment may be made more stimulating. In 
the case of infants, however, stimulating topical remedies are very 
rarely to be employed. An eczema of the scalp that has once entered 
upon resolution, in an infant or a child, should generally be soothed 
and protected. 

Many children thus affected are in excellent general health, and 
require no internal medication. The prevailing tendency among the 
laity and even among many practitioners to dose these little ones with 
mercury, arsenic, iodides, and other "blood medicines" cannot be 
condemned too severely. Proper nourishment, elimination, and hy- 
gienic surroundings should be sought in every case. 

The treatment of erythematous and chronic eczema of the scalp 
in adults is described under dermatitis seborrheica. 

Eczema of the Face (Eczema Faciei). — Erythematous eczema of 
the face in adults is projected prominently among the varieties of 
the disease by its uniformity of type. It occurs in early and in 
middle life and in advanced years, and is a particularly intractable 
ailment. In well-marked cases the forehead, cheeks, eyelids, and nose 
of the patient are involved, exhibiting an infiltrated, usually dusky- 
red, often symmetrical patch of disease, the affected surface being 
slightly elevated above the level of the sound skin. This surface is 
uniformly smooth and reddened ; occasionally, near the root of the 
nose and about the lower line of the forehead minute, closely set 
papules are visible. Very slight oozing, especially after irritation, may 
be noticed. At the height of the disease, or in its involution, exceed- 
ingly fine scales form, which are scarcely perceptibly shed from the 
surface. The eyelids, especially the lower lids in advanced years, be- 
come puffy. The line of demarcation of the attacked surface is unusu- 
ally distinct, and rarely invades the scalp-border or the region of the 
beard. Itching is at times intense, the patient bitterly complaining 
of it and usually preferring to rub the face with the hands or with 
pieces of cloth. Sometimes, however, the face is well scratched with 
the finger-nails, and excoriations and blood-crusts disfigure the coun- 
tenance. Patients of intelligence usually describe the itching as par- 
oxysmal and as starting at the root of the nose, whence it travels up- 
ward over the forehead and laterally to the brows, often in the line of 
the supraorbital nerves. At the root of the nose the exudative process 
is most marked. The eruption is seen also in asymmetrically dis- 
posed patches of various sizes, with islets of sound skin between. In 
typical cases the hairs of the eyebrow are reduced to a stubble by 
constant rubbing. In resolution of the symmetrical form this condi- 
tion of the eyebrows is commonly observed. 

Patients thus affected are often those whose faces have especially 
been exposed to irritation, such as locomotive-engineers, pilots of sea- 
going vessels, mechanics in trades in which the hands are soiled with 
irritants and afterward applied to the face, and women spending 
hours of each day over the laundry-tub or the kitchen-stove. In each 
class the operation of the cause is made manifest by the exacerbation 
of the disease after exposure. 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 229 

Diagnosis. — The affection is most commonly mistaken for erysipe- 
las, a disorder from which it is readily differentiated by the chroni- 
city of its course. The latter feature is particularly characteristic of 
this form of eczema, which is rarely completely relieved after the age 
of sixty within a twelve-month, and which, when it has existed for a 
long period of time, is particularly obstinate under the best treatment, 
recurring with exasperating frequency upon exposure of the face to 
atmospheric changes. The great vascularity, abundant supply of 
sensory nerves, and necessary exposure of the face explain this pecu- 
liarity. In its management the lotions and dusting-powders described 
under the treatment of acute eczema fulfil an important part. In 
some cases pastes, ointments, plasters, or the glycogelatins give better 
results than lotions and powders. Soothing applications should al- 
ways be first employed; and more stimulating applications may be 
tried later. In many cases Pick's " linimentum exsiccans " or traga- 
canth-glycerin mucilage furnishes a pleasant and effective application. 

In obstinate cases tar and other stimulating remedies recom- 
mended for chronic eczema should be employed. It is well to re- 
member in the management of any case that while a tarry application 
may be well tolerated over one part, as, for example, on the cheeks 
and near the nose, in another part, as, for example, over the eyelids, a 
zinc-salve may better be employed in the same individual. 

In patients of younger years and especially in infants the face is 
apt to display vesicular and pustular phases of the disease, forms 
more often of acute eczema, and correspondingly more manageable. 

The itching, and especially the burning sensations, are prone to be 
severe, and crusts rapidly form. In infants the picture presented is 
often similar to that seen in the scalp, except that there are no hairs 
to be matted into crusts and there is often a reddish blush at the edge 
of the patch or where the crust has been removed, the redness of 
the oozing surface being somewhat more marked than in the similar 
patches on the less vascular scalp. The scratching in these little 
patients is severe, crusts being torn off in part or wholly; blood- 
crusted excoriations are common. In this way the area of surface 
involved is clearly extended, sleep is greatly disturbed, and the irrita- 
bility and fretfulness of the child bear heavily upon its general nutri- 
tion. In severe cases of long standing the mental tone of the little 
sufferers becomes singularly perverted and their character unques- 
tionably changed. The eczema of the cheeks and chin of infants 
appears at times to stand in close relation to the eruption of the teeth. 

This chain of formidable symptoms well linked together will often 
bid defiance to the most skilled effort to impart ease to the tormented 
skin. In such cases the harness employed by White, of Boston, fills 
an important office: a skull-cap, made of firm old cotton or linen 
cloth, is closely fitted to the calvarium, and a mask of the same mate- 
rial is shaped to the face with exactly placed apertures for the eyes, 
nose, mouth, and ears. This mask is gathered in beneath the chin 
and laps over two inches at the back of the head ; it may be used only 



230 niPEUMMlAS AND INFLAMMATIONS. 

during sleep, or, in aggravated cases, also during the hours of wake- 
fulness. A species of straight-jacket is made by passing the head of 
the child through a hole in the closed end of a small pillow-case, 
which is then drawn down over the body and arms, and the latter con- 
fined at the sides by stitching or pinning the case together between the 
trunk and the upper extremities. This jacket is finally secured by 
similar means between the thighs. When it is necessary to imprison 
the lower extremities they are similarly secured by pins within the 
pillow-case ; and the outer edge of such trousers can be fastened to the 
bed or the cushion on which the child reclines. This treatment does 
not preclude the employment of the washes, ointments, etc., which 
are to be neatly applied next the skin beneath the " trousers " or the 
" jacket." The ointment or other application is thus retained in posi- 
tion, rest and protection from all external irritation are given to the 
tormented skin, and its natural tendency to repair soon brightens 
the case. 

Treatment. — For the treatment of these cases are recommended the 
black-wash and zinc-salve treatment, the diachylon salve, Lassar paste, 
boric acid ointment, lead lotions, glycerole of starch, and other prepar- 
ations and methods described in full in the treatment of acute eczema. 
These cases are often very capricious in their course, and treatment 
may have to be changed frequently to meet the varying conditions. 

Eczema of the Lips (Eczema Labiorum). — Reference has al- 
ready been made to the obstinacy of eczema occurring near the mucous 
outlets of the body, a result due, probably, to the secretion furnished 
by the adjacent mucous tracts. The lips furnish an illustration alike 
of this pertinacity and aggravation. Their frequent motions in mas- 
tication and articulation aggravate an eczema, which is, moreover, apt 
to be teased by a no less frequent thrusting out of the tongue (where 
there is no beard) to wet the parts with mucus and saliva. Vesicular, 
pustular, squamous, and erythematous lesions occur at one point, or 
along the entire line of the lip, with frequently resulting crusts and 
fissures. The vermilion border of the lips commonly participates 
in the process. The lips become hot, and sometimes much thickened 
by the swelling and infiltration, their mucous faces being rarely im- 
plicated. Scarlet, dull-red,, and other peculiarly purplish hues of 
the vermilion border become visible. The parts are more picked 
than scratched, though the itching at times is severe. The pustular 
and vesicular forms are more common in children. The erythema- 
tous form, its reddened outline roughened by scales evenly projected 
beyond the vermilion border, is rather an affection of maturer years. 
In many cases the disease is aggravated by nasal discharges which 
flow over the upper lip, giving the latter an elephantiasic aspect. 
In eczema of the hairy lip the symptoms and treatment are those 
of eczema barbae. 

Diagnosis. — The diagnosis is between hyphogenous sycosis, herpes 
labialis, epithelioma, and syphilis. The first is accompanied by 
loosening of the hairs, caused by a vegetable parasite; the second 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 231 

is vesicular in lesion, brief of duration, and trivial in severity; the 
third is a disease of advanced years rather than of early and middle 
life, and is accompanied by characteristic induration and ulceration 
and not by itching. Syphilis is fond of the angles of the lips; in 
most cases, when thus limited, typical mucous patches of the mouth 
can be discovered. The lesions of syphilis at the angles of the mouth 
are seldom linear fissures, but are more often definitely outlined 
erosions, secreting a puriform mucus. Pustules and resulting crusts 
of the lips and the nose in female children are often eczematoid fea- 
tures due to the picking and scratching caused by lice upon the scalp. 
Treatment. — In male patients the pipe, the cigarette, and the cigar, 
as well as the tobacco chewed and expectorated, may aggravate the 
malady. In all cases it is obstinate and calls for either emollient, 
stimulant, or protective applications. In eczema of the lips display- 
ing acute and painful symptoms frequent fomentations of the part 
with soft rags dipped in hot mucilaginous and alkaline waters will aid 
in controlling the swelling and in alleviating the pain. After such 
bathing some soothing ointment should be applied. In chronic cases, 
in which stimulation is demanded, this can be effected at the time of 
dressing, the parts being subsequently protected by collodion or other 
material. Carbolic acid and silver nitrate are often needed for such 



Equal parts of tincture of benzoin, alcohol, and glycerin applied 
frequently during the day supply an excellent combination for the ver- 
milion border. For protecting this portion of the lip cold-cream 
or other simple salve to which has been added enough white wax to 
make as stiff an ointment as can be spread with the finger, is recom- 
mended. A drachm (4.) of the compound tincture of benzoin with 5 
to 20 (0.33-1.33) grains of tannin may often be added to such 
ointment with good results. 

Eczema of the Nostrils (Eczema N avium) is naturally often as- 
sociated with a chronic coryza. Inasmuch as one of the common 
symptoms of hereditary syphilis is "the snuffles," the physician 
should carefully exclude the possibility of such disorder in every 
instance when an infant with coryza exhibits an "eczema" of the 
nares or of the lips. The age of the little patient, an inspection of its 
anal region (which should never be omitted in infantile eczema), and 
the history of the case will throw considerable light upon this im- 
portant question. 

Whether occurring in the adolescent or the child, the disease may 
linger only upon the alffi in the pustular or the squamous form, or 
may block the nares with crusts. In infants this obstruction enforces 
respiration with an open mouth, and the grasp of the nipple by the 
lips is thus interrupted either by respiratory acts or cries of agita- 
tion. The Schneiderian membrane participates in the inflamma- 
tory process and pours out its secretion upon the eczematous skin. 
This membrane when inspected is seen to be either raw and succulent, 
or in a condition analogous to that seen in pharyngitis sicca, that is, 



232 BYPEB&MIAS AND INFLAMMATIONS. 

dry, glazed, and free from discharge. The nostrils are often thick- 
ened in consequence of infiltration or are fissured, especially at the 
lines of the nares, laterally and inferiorly. In severe cases, and when 
the lips participate in this process, the pouting, swollen, and distorted 
organs suggest the snout of the lower animals. Adults, as a result, 
frequently suffer from coccogenous sycosis and furunculosis. 

Treatment. — In treating these cases all crusts should he removed 
and the parts carefully be protected. Picking of the nose in children 
should be prevented, if needful, by the " straight-jacket." Pencillings 
with compound tincture of benzoin, iodized phenol, silver nitrate, or 
collodion often prove serviceable. 

In softening crusts oil may be freely used. For this purpose the 
warm carbolized oil-spray of the atomizer or a glycerin-lotion answers 
well. After softening and removal of the crusts a simple ointment 
containing from 5 to 20 grains (0.33-1.33) of boric acid, or from 
2 to 10 (0.133-0.66) grains of white precipitate to the ounce (30.) 
may be used. A weak citrine ointment is often serviceable. When 
the disease extends well up the nares Neumann employs bougies 
made by combining 2 grains (0.133) of zinc-oxide with 16 grains 
(LOG) of cocoa-butter. Hardaway recommends equal parts of cold- 
cream salve and glycerole of lead subacetate. 

Eczema of the Ears (Eczema Aurium). — The ears are affected 
with eczema, both in infancy and maturer years, rather more often in 
women and children, the disease being limited to the whole or part of 
the organ, or extending backward over the post-auricular region, or 
downward over the ramus of the superior maxilla. The eczema may 
be acute or be chronic, and commonly originates in seborrheic derma- 
titis (which see) of the scalp or the face, but may find its origin in 
chronic or catarrhal discharges from the external auditory meatus; in 
the growth of aspergillus in the same canal ; in exposure to tempera- 
ture-changes, especially with high winds; in frostbite; in the irrita- 
tion set up by pediculi and by the auricular rim of the frame of 
spectacles ; in the toxic effect induced by the hook of cheap ear-rings 
and dyed bonnet ribbons ; in the traumatism of ear-piercing ; and in 
the habit of unnecessarily picking the ear to relieve it of wax or of 
trifling sensations of irritation. 

The pustular and moist forms are common at the superior, infe- 
rior, and posterior boundaries of the pinna, where a linear fissure is 
apt to form in the line of the angle made by the auricle with the 
plane of the adjacent integument. The motions imparted to the 
ear by handling it, or by placing the hat on the head and tying hat- 
strings over the ear, always tend to aggravate the disorder. Long 
hairs worn over the ears have a similar effect by the production of 
friction and the retention of heat. The lobules may display the 
erythematous and scaly phases of eczema, becoming infiltrated, and 
having a deformed appearance and lurid-red color, the affection 
pursuing an indolent course. The lobules alone of both ears in 
young women may similarly be affected, and may exhibit these phe- 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 233 

nomena for consecutive years. Often the chronic inflammation lays 
the foundation for a keloid growth, an accident of inflammatory 
processes in other parts. 

Sometimes the entire auricles are uniformly dark red, infiltrated, 
alternately weeping and scaling, and project to a noticeable extent 
from the side of the head in consequence of their increase in bulk. 
The itching is usually more annoying than severe, being accompanied 
by a characteristic sensation of tenseness and fulness of the part. 
Like the eczema which occurs at the other mucous outlets of the body, 
the affection in the meatus is particularly obstinate when it assumes 
a chronic form. Symmetry to the extent of involving both ears, 
though commonly to a different degree in each, is rather the rule 
than the exception, and is doubtless due to the simultaneous operation 
of effective causes. 

Diagnosis. — The diagnosis is between erysipelas, seborrhoea (which 
occasionally occurs in the concha of the auricle), erythema simplex 
and multiforme, and dermatitis calorica. 

Treatment. — The treatment should at first be soothing and protec- 
tive by zinc-salve or diachylon ointment or by soothing and astringent 
lotions; afterward stimulation may be needed. A firm bandaging 
of the ears to the head may be required to support them, to prevent 
irregular pressure (of the head upon the pillow), and to retain ex- 
ternal medicaments. In chronic cases stimulant applications are 
often well tolerated, and sulphur, salicylic acid, ichthyol, and tar 
ointments here play an important part. Treatment appropriate to 
the otitis externa or of the aspergillus may be required. Bulkley 
recommends an ointment of 1 drachm (4.) of tannin to the ounce 
(30.), deeply and thoroughly passed into the meatus on a camel's- 
hair brush. French authors generally advise small tampons smeared 
with an ointment and left in the canal. Burnett employs 2 drachms 
(8.) of oil of tar to 1 ounce (30.) of alcohol. Great benefit is derived 
from painting the indolent surfaces with solutions of silver nitrate. 
The intractable forms almost invariably affect adults, in whom there 
is usually a history of improvement under treatment, followed by 
relapse due to exposure to wind, heat, cold, or other sources of irrita- 
tion. Many cases require the treatment recommended for dermatitis 
seborrhoi'ca; others may require radiotherapy. 

In Eczema of the Eyelids (Eczema Palpebrarum) the free edges of 
the eyelid, or the skin over the orbital margin of the tarsal cartilage, 
may chiefly be affected, both in children and adults. When the free 
edge of the eyelid is involved there is present a species of coccogenous 
sycosis, the hair-follicles becoming inflamed and furnishing a puru- 
lent discharge which may agglutinate the lids. The latter are thick- 
ened and swollen, become the seat of moderate itching, are picked 
rather than scratched, and exhibit minute crusts between, or glued to 
the hairs. The disorder is often accompanied by a seborrhoea of the 
Meibomian follicles, and is described by oculists under the designation 
of " blepharitis" or " tinea tarsi." Inasmuch as the facial expression 



234 BYPER&MIAS AND INFLAMMATIONS. 

is characteristic when the eyelids are thus involved, patients exhibit- 
ing this form of eczema are usually set down as " scrofulous," though 
the disorder occurs in many individuals with no other sign of strauma, 
and eczema surely is not such a sign. 

Fissures occasionally form at the commissure of the eyelids. The 
disorder may complicate eczema of other parts of the face. In erythe- 
matous eczema faciei of adults there is usually swelling with puffi- 
ness, especially of the lower eyelid. The conjunctiva may or may 
not be implicated. A chronic granular condition of the eyelids is 
not noted as frequently as might be suggested a priori. 

Diagnosis, — In the diagnosis care must be taken to exclude syph- 
ilis, lupus, and pediculi. Piedra of the eyelashes must not be over- 
looked. Instead of the ordinary nits of the lash, there are in such 
cases jet-black, pin-head-sized masses of ivory-like hardness attached 
to the hairs. 

Treatment. — The edges of the eyelids should be cleansed carefully 
with a weak alkaline solution and a soft camel's-hair brush whenever 
the eyelid is involved, and then as carefully be dried and anointed 
with cold-cream salve. In acute cases the closed eyelids may be 
bathed frequently with warm solutions of boric acid or of borax (1 to 

2 drachms (4. to 8.) to the pint (480.)), and strips of soft lint, 
soaked in the same solution, or in a very dilute glycerin and carbolic 
acid lotion may be laid over the closed lids for as long periods during 
the day as these remedies are comfortably tolerated. In chronic cases 
red mercuric oxide ointment, from 1 grain to 10 (0.066-0.66) to the 
ounce (30.), with or without an equal quantity of salicylic acid, is 
held in high esteem. Ophthalmologists, in the treatment of this af- 
fection, are fond of using an ointment of yellow mercuric oxide, 1 to 

3 grains (0.066 to 0.2) to the drachm (4.). In place of these mercur- 
ials the unguentum hydrargyri nitratis, 1 part to 6 of cold-cream 
salve, may be applied, or resorcin 1 part to 100 of simple unguent. 
Epilation of the eyelashes may be necessary. Pencillings with solu- 
tions of silver nitrate in various strengths are also useful in chronic 
cases, but these solutions must carefully be confined to the eyelids, 
and not be suffered to come in contact with the conjunctiva. Exces- 
sive use of the eyes must be prohibited. 

Eczema of the Beard {Eczema Barbae). — Eczema may involve 
the region of the beard only, or it may exist in connection with the 
disease on other parts of the face. 

In recent cases there is no loss of hair, but in those of long stand- 
ing the hairs are thinned and fail to hide completely the reddened 
surface beneath, covered here and there with pAstules or displaying 
floors of broken pustules, dried inflammatory products, yellowish and 
greenish scales and crusts. Beneath the crusts the surface is smooth, 
not lumpy as in hyphogenous sycosis. The hair-follicles are not 
solely involved, as in the coccogenous form of that disease, but evi- 
dently they and also the integument between them are inflamed. In 
chronic cases the symptoms may be those of erythematous and scaling 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 235 

eczema. In recent eczema the hairs are not loosened in their follicles, 
but in chronic cases such loosening does occur, and there is a true 
defluvium capillitii. The disorder is one primarily involving the 
skin, and secondarily the hair-follicle, extending smoothly over the 
surface, as smoothly as an eczema on the cheek of a woman. There 
is commonly a certain degree of symmetry, to the extent at least of 
involving the beard in different degrees on both cheeks at once, or the 
chin on both sides ; often the symmetry is perfect. Symmetry is rare 
in the several sycoses of the same part. 

The disease is accompanied by itching, rarely so severe as upon 
the smooth parts of the face, is particularly obstinate, and is ex- 
tremely disfiguring. When extending into the region of the beard 
from other parts there is usually association with eczema of the ears. 
When limited to the region of the moustache there may be an eczema 
of the nares and a chronic nasal catarrh or seborrheic dermatitis. 

Diagnosis. — The condition is more superficial than that of hyphog- 
enous sycosis. There are no deep-seated nodules as in the latter dis- 
ease. From coccogenous sycosis eczema of the bearded region is dif- 
ferentiated with greater difficulty, as the two conditions have many 
features in common. Sycosis is primarily an inflammation of the 
hair-follicles, a distinct folliculitis, and presents a characteristic pus- 
tule pierced by a hair at the mouth of the follicle. In this disease 
there are also found papules and small tubercles. Though there is a 
superficial inflammation of the follicle in eczema of the beard, a dis- 
tinct folliculitis is not present and there are no papules or tubercles. 
Moreover, the skin-surface between the follicles is evenly involved in 
eczema, while it frequently escapes wholly or in part in sycosis. Ec- 
zema quite commonly coexists on other portions of the face, while 
sycosis is limited strictly to the region of the beard. It must be re- 
membered, however, that an eczema barbae is often the forerunner of a 
genuine coccogenous sycosis. 

Treatment. — The treatment of recent cases of eczema of the bearded 
region is that of similar phases of the disease on other parts of the 
body, by means of the simpler lotions and ointments, but cases of long 
standing are exceedingly stubborn and frequently require vigorous 
measures. After removing crusts and other accumulations by soak- 
ing with oil and thorough washing with soap and water the beard 
must be wholly removed. Clipping short the hairs of the face will 
not answer, though this is generally preferred by the patient as ex- 
posing to a less degree the unsightly surface beneath. Nothing short 
of epilation or of shaving, and repeated shaving every second day, 
will effect the desired result in chronic cases. As soon as the disease 
is reduced practically to an eczema of the non-hairy parts it improves 
in proportion to its distance from the mucous outlets of the body. 
When limited to the bearded cheeks the most obstinate cases in the 
course of a single month may be robbed of one-half their unsightli- 
ness. The patient should be encouraged by reminding him that 
usually it is but the first step which costs, each succeeding removal 



236 HYPEREMIAS AND INFLAMMATIONS. 

of the beard being accomplished with greater comfort to himself 
physically and mentally. After each shaving the skin should be 
bathed with water as hot as tolerable, and, if at night, a lotion or an 
ointment, or the latter after the former, may be used. The salves 
most useful for this purpose are sulphur, 10 to 60 grains to the 
ounce (0.66-4. to 30.) ; diachylon ointment with salicylic acid, 5 to 
10 grains to the ounce (0.33-0.66 to 30.), and zinc or tar ointment. 
Rarely, the surface requires painting with weak solutions of silver 
nitrate. As the condition improves a dusting-powder will afford 
needed protection during the day. The shaving should be continued 
for months after the disease is at an end. 

Eczema of the Genital Organs (Eczema Genitalium) is remark- 
able for the severity of the subjective sensations it occasions; for its 
tendency to persistence, recrudescence, and nocturnal exacerbation ; 
and for the liability to the production of the sexual orgasm by the act 
of scratching. In men the surfaces most often involved are the an- 
terior, the posterior, or lateral faces of the scrotum where they meet 
the thigh, though the surface of the penis, as also that of the pubes 
and the perineum, may be involved. In women the labia majora, 
more rarely the labia minora and vestibule of the vagina, are affected, 
with occasionally extension of the disease to the same contiguous parts 
as in men. 

Eczema thus located is, as a French writer has well said, " a dry 
disease in a moist locality." Vesicular and pustular forms are much 
rarer than the erythematous, the papular, the papulo-squamous, and 
the erythemato-squamous. In women the moister forms are more 
frequent, doubtless because of the wider mucous outlet and the more 
extensive mucous tract in the vicinage. The labia are then heightened 
in color, cedematous, agglutinated by crusts, and often torn viciously 
by the finger-nails. Blood-crusted excoriations are seen in most of the 
severe cases. An eczema intertrigo at the labio-femoral angle is com- 
mon. Over the whole may be poured the normal or pathologically 
altered secretions from uterus or vagina. The disease, however, is 
sufficiently common after the menopause, when there is usually 
physiological atrophy of the uterus. 

The typical disease in men is recognized in the thickened, red- 
dened, perhaps slightly scaling integument of the scrotum, which 
may also be fissured, excoriated by the finger-nails, or covered with 
blood-crusts. Torn papules, even tubercles and nodose swellings may 
be closely packed together, exhibiting a lurid or even purplish hue. 
In aggravated cases the infiltration is so great as to deform the parts, 
increasing the thickness and deepening the normal furrows of the 
scrotal integument to the grade of many times its normal dimensions, 
producing thus an elephantiasic appearance. In eczema of the penis 
also the prominent symptoms are oedema, itching, and redness with 
slight scaliness. 

In both sexes, as before indicated, attempts on the part of the suf- 
ferer to relieve the itching are often as severe and prolonged as they 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 237 

are ingenious. Commonly no relief is obtained until a serous sweat- 
ing or weeping of the thickened tissues is induced by the friction. 
Inasmuch as the latter in severe cases is frequently repeated, the phys- 
ical dangers are obvious. 

Apart from this, however, the disorder has a marked tendency to 
disturb the mental tone and the general health. Shame deters many 
from seeking speedy relief, so that cases of long standing are often 
registered by the physician. Though unconnected with venereal dis- 
ease of any kind, there is for many a special dread of an eczema of 
these parts simply because of its location. With sleep disturbed, the 
mind agitated, and the nervous system teased by an intolerable pru- 
ritus, one can scarcely wonder at the eloquence with which many 
patients describe their sufferings. It is a disease of middle life and 
of advanced years. It is rare to see a well-marked, obstinate case in 
a child. 

The causes, exciting and aggravating, of eczema of the genital 
region are often obscure, but undoubtedly depend largely upon heat ; 
moisture, and friction. These factors are favored — first, by the effect 
of gravity, the organs in question being situated, when the body is in 
the erect position, at the inferior apex of the double cone forming the 
trunk and being thus subject to the force of gravity; second, by the 
arrangement of the clothing in both sexes, by which heat and friction- 
effects are heightened ; third, by uncleanliness, the secretions and dis- 
charges from the adjacent mucous tracts being suffered to accumulate 
upon the person. The cause may lie in some disturbance of the 
genital organs or of the general nervous system. 

In many eczemas of the surface, and especially those of the genital 
region, the urine will be found to contain albumin or sugar, and these 
conditions have been supposed to lie at the root of the eczema. Aside 
from the fact that the presence of these substances in the urine points 
usually to constitutional abnormalities which in themselves might 
predispose the skin to eczematous attacks, it may be said of sugar that 
it is, per se, a profound irritant to the skin and mucous membranes. 
Any part moistened constantly or intermittently with saccharine 
urine will respond eventually with an outburst of eczema. Sugar 
and albumin are known, however, to be producible in urine by ex- 
ternal irritants, among which are cutaneous diseases. If a patient 
with saccharine urine and severe genital eczema be kept in bed in the 
recumbent position for a few days, while any soothing application 
productive of comfort is continuously applied to the tender and ex- 
coriated surface, the sugar may rapidly disappear from the urine. 
Many cases of extensive and severe eczema of the genital region in 
both sexes occur in patients in whom careful and repeated examina- 
tion of the urine fails to reveal sugar, but the practitioner is urged 
never to omit such examination in his treatment of a typical case. 
Genital eczema occurring with glycosuria is one of a group of disor- 
ders named by French authors Diabetides Genitales. 

Diagnosis.* — The diagnosis of eczema of the genital organs is be- 



238 HYPEREMIAS AND INFLAMMATIONS. 

tween ringworm, acne, pruritus, scabies, pediculosis, the venereal 
disorders, and herpes progenitalis. The first-named affection may 
occur alone or may induce or may be grafted upon the eczema. 
Ringworm may be recognized by the discovery of the trichophyton, 
and is clinically distinguished by the crescentic edge of the spread- 
ing patch, its convex border looking away from the genital centre. 
The "follicular vulvitis" of gynaecological authors is a genital acne 
and is manifestly limited to the glands and the peri-glandular tissues. 
The same is true of bromine and iodine acne, which may be developed 
in the same situation in both sexes. Genital pruritus may beget 
an eczema from scratching, but it is accompanied primarily by no 
skin-lesion. The pruritic papular lesions of scabies upon the male 
genitalia are always associated with typical manifestations elsewhere 
on the body. The pubic louse is visible to the eye, as are also its 
reddish excreta and nits. The ulcers and sclerosis of chancroid 
and primary syphilis are rarely accompanied by pruritus, and, 
though occasionally multiple, never exhibit diffuse patches of disease. 
Syphilodermata are recognizable by their characteristic features and 
the history of an infectious disease. In herpes progenitalis there 
are precedent burning, smarting, or neuralgic sensations, the occur- 
rence of vesicles or groups of vesicles (lesions rare in eczema of the 
genitals), and frequent limitation of the disorder to the mucous sur- 
faces or to the muco-cutaneous lip by which such surfaces are 
bounded. In eczema these boundaries arc usually respected and the 
disease is much more strictly cutaneous. 

Treatment. — The treatment is to be conducted on the general prin- 
ciples heretofore outlined. Careful attention should be directed to 
the diet and the habits of living. In diabetic cases every effort should 
be made to remove or reduce the sugar present in the urine by an 
appropriate regimen. Sponging of the genital region with alkaline 
water as hot as can well be tolerated, followed by the blander lotions, 
oils, and ointments at night, and the use of antipruritic dusting- 
powders in the daytime, must not be omitted. One per cent, solu- 
tions of formalin are of value. In eczema of the scrotum a sus- 
pensory bandage lined with lint which is wet with a lotion, smeared 
with an ointment, or thoroughly covered with a powder, can usually 
be employed with advantage. The habit of scratching must be broken 
up at all hazards. In chronic cases treatment by soft soap and 
diachylon ointment will be found useful. Caustics, solutions of 
mercuric chloride and other mercurials, carbolic acid, and especially 
the tarry compounds, are often necessary. The Lassar paste also 
may be used with advantage. In some persistent cases with decided 
infiltration, radiotherapy has given prompt relief. 

The following formulae are useful in allaying the irritation of 
some acute and subacute cases : 

$ Liniment, calcis, f^ v > 120 

Zinci oxid., 3ij; 8 

Glycerini, f 3ij ; 8 

Liq. calcis, f^iv; 120 M. 

Sig. Lotion to be applied at night after bathing the parts with hot water. 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 239 



M. 



Liniment, ealeis, 


f#v; 


120! 


Acid, hydrocyanic, dil., 


ttjj 


4 


Liq. plumbi subacetat., 


f3ij; 


8 


Glycerini, 


f3ij; 


8 


Aq. ros., 


ad f^viij; 


240 



Sig. Cream, for application on strips of old linen. 



Exceedingly obstinate eczema of the pubic region is benefited by 
shaving and subsequent appropriate treatment. When complicated 
by intertrigo the latter condition requires special relief by the inter- 
position of soft lint spread with an ointment. 

Eczema of the Anus and Anal Region (Eczema Ani) in its 
etiology and characteristics, is closely allied to the same disease in 
the genital region. The presence of ascarides and hemorrhoids 
occasionally induces or aggravates the disorder; though this compli- 
cation is rarer than is commonly supposed. Multitudes of men and 
women who suffer from piles never complain of eczema. The eczema 
may occur in erythematous, squamous, or papular form, in the order 
named ; thus exhibiting here, as on the genitals, " a dry disease in a 
moist locality." 

The redness, infiltration, and itching may be limited to the verge 
of the anus, radiate from the latter in stellate lines, creep upward 
between the nates in the cleft, sweep forward over the perineum to 
the genital region, or extend laterally with intermediate intertrigo 
over the inner face of each 'thigh. Karely the buttocks are covered 
with the same lesions. Fissures and excoriations are apt to appear 
about the anal orifice. 

This disease is common in infancy, when want of attention to the 
removal of the napkin is a fertile source of mischief ; and also, in per- 
sons in middle life and in advanced years, when it becomes particu- 
larly intractable. The itching is intense in the latter class, with 
frequent nocturnal exacerbation. Unfortunately the scratching is 
often reflex, and is practised during sleep, from which the patient 
is often aroused by his or her manipulations. Pollutions fully recog- 
nized, or occurring during profound sleep, or, more usually, in states 
of semi-consciousness, complicate certain cases; defecation . becomes 
painful; the harassed nervous system of the sufferer is often in a 
deplorably wretched condition. In cases of long standing the usual 
congested, thickened, infiltrated, and almost elephantiasic appear- 
ance of the skin is presented, with occasional fissures and exaggera- 
tion of the natural furrows. The part may simulate in aspect the 
formidable conditions discovered in passive pederasty. 

Treatment. — In the treatment of these cases the use of very hot 
water by sponging, and the subsequent application of ointments, in 
some cases mild but in others stimulating, have yielded the best results. 
In the case of infants dusting-powders and the blander ointments are 
alone to be employed; in adults, especially in chronic cases, tar in 
some form is especially valuable. Here the Lassar paste may be 
applied or tincture of tar be freely painted over the surface, or there 
may be used one of the tarry ointm§nts ; such as the Wilkinson salve ? 



3ij; 


2 


66 


3j; 


1 


33 


£ r - i J ; 




133 


3j; 


4 




SJ; 


30 


M 



240 HYPEREMIAS AND INFLAMMATIONS. 

of sufficient firmness to retain its form as an unguent when subjected 
to the heat of the part. Caustics, especially the silver nitrate in 
crayon, are useful when there are fissures and excoriations. Corrosive 
sublimate, % to V 2 of a grain (0.016-0.033) to 4 ounces (120.) of 
milk of almonds ; Squire's glycerole of plumbic subacetate, M> drachm 
(2.) in 2 ounces (60.) of glycerin and water, or as a substitute for 
the latter, soft soap and diachylon plaster, are here of special service. 
Almond-oil, or an ointment containing 2 to 10 per cent, of carbolic 
acid, often gives relief. Duhring recommends the following: 

IJ Sulphur, praecipitat., 
Naphtol., 
Morph. acet., 
Zinci carb., 
Ungt. aq. ros., 

When defecation is painful the stools should be semiliquid in 
order to insure non-aggravation of the local disorder, not, it need 
scarcely be remarked, with a view to eliminating any materies morbi 
by purgation. Small tampons of cotton may be smeared with an 
emollient ointment and gently be inserted for a short distance within 
the anus. Tincture of benzoin, 1 part to 8 of vaselin, may be used for 
this purpose. Kaposi recommends cocoa-butter suppositories, con- 
taining zinc oxide with belladonna or opium. When complicated by 
true fissure of the anus the sphincter ani must be stretched or divided, 
or dilated with medicated bougies. At night a cataplasm is applied. 
The parts are washed frequently with tepid water, and the anal tam- 
pons are smeared with cocaine. During the day zinc-oxide salve, 30 
grains (2.) to the ounce (30.) of vaselin, is applied, and over this 
are thoroughly sprinkled equal parts of zinc-oxide and bismuth-sub- 
nitrate in fine powder. Collodion medicated with 1 to 3 per cent. 
of salicylic acid, and lotions containing 1 scruple (1.33) of silver 
nitrate to the ounce (30.), are of great value in many cases. Besnier 
recommends the use of a clyster after each bowel-movement, the 
fluid being retained for only a short time. 

Veiel prefers the cautious use of chrysarobin to tar, employing 
the latter either in the form of spirits or as tar-diachylon, 1 part to 
20, gradually increasing in strength. Carbolic acid, 1 to 5 per cent., 
and glycerin, 2 to 10 per cent., in elder-flower water or in almond- 
emulsion, are specially indicated in fleshy women when the disorder, 
as is often the case, is complicated with intertrigo. 

The key to most cases of anal eczema is to be sought in the dietary. 
This disorder, in adults particularly, is likely to be a significant 
symptom of gout, and without the dietetic and medicinal treatment of 
that condition no local applications avail. Tobacco and alcohol are 
invariably to be excluded in the case of patients of this class ; and blue 
pill, alkalies, colchicum, and salicylates are often needed. It is in 
these manifestations of eczema that health-resorts furnish their best 
results, necessitating and inviting, as they often do, an out-door life, 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 241 

an appropriate regimen, and an avoidance of stimulants. Even in 
children and infants, when there are no ascarides in the rectum or the 
vulva, the dietetic management of the patient should never be 
neglected. 

Eczema of the Nipple and Breast of Women (Eczema Mam- 
mce). — Eczema of the mammary region is common in nursing- 
women, either from the irritation produced by the mouth of the 
infant, or, more commonly, in consequence of a galactorrhea. Ec- 
zema intertrigo is common below and between the breasts. The 
eczema here is vesicular, erythematous, or squamous in type, with 
fissures at the apex, the side, or the base of the nipple. The serous 
ooze from the infiltrated areas dries as usual into light-colored crusts. 
There are the characteristic burning and itching. The disease may 
occur on one or both breasts, and, especially with a galactorrhcea in 
the summer, may spread extensively, covering both breasts, the sur- 
face of the belly, and the intermammary region. The circumscribed 
forms occur also in pregnant or in unmarried women, and are to be 
distinguished from scabies, which in women is prone to occur upon 
the breast. 

Paget' s Disease, which in its early stages presents all the appear- 
ances of an eczema, is more fully described in this treatise among the 
epitheliomata ; it is sufficient here to call attention to the important 
fact that a fairly well-defined eczematoid patch, surrounding the 
areola of the nipple or that organ only, with infiltration, itching, and 
possibly a fissure of the nipple, or a crust covering a superficial ero- 
sion, may be the sign of an epitheliomatous change already advanced 
either in the affected part only or deeper in the galactiferous ducts 
of the breast itself. 

Treatment. — The treatment of mammary eczema is that of eczema 
in general. In severe cases with galactorrhea nothing short of 
weaning the child and a cessation of all demands upon the breast will 
insure relief. Every effort should be made in milder cases to avoid 
this dernier ressort. The nipple should be thoroughly cleansed after 
each nursing. As a rule, hot water and soap may be used for the 
purpose without harm and usually with benefit. Any fissures exist- 
ing should be then painted with compound tincture of benzoin, tinc- 
ture of myrrh containing 1 grain of mercuric chloride to each 
ounce (0.06 to 30.) or weak solutions (2-15 per cent.) of silver ni- 
trate. The whole should immediately be covered with a protective 
ointment or paste. The zinc oxide or diachylon ointment spread on 
lint serves the purpose well. Salicylated and borated pastes are some- 
times preferable. Lister's salve often does well : 

]£ Acid, boracic. subtil, pulv., \ aa, er xv • aa 

Cerae alb., J s ■ > 



Paraffin., 
01. amygdal 



,} 



In some instances stronger and more stimulating remedies are 
16 



242 HYPEREMIAS AND INFLAMMATIONS. 

necessary. Before the child takes the breast all but the simplest 
preparations should be entirely removed with oil or other unirritating 
agent. 

Fournier recommends a breast-plate of caoutchouc. When the 
disease is limited to the nipple and areola in nursing-women the glass- 
and rubber-apparatus sold in the shops may be tried in the hope of 
saving the nipple from mouth-contacts in nursing. Sometimes they 
answer admirably; often they utterly fail. Dusting-powders are 
valuable in mild cases, and for any intertrigo that may exist between 
and beneath the breasts. 

Eczema of the Umbilicus (Eczema Umbilici) is briefly de- 
scribed in the chapter devoted to Seborrhcea. In most cases it is 
either induced or is aggravated by a soborrhoea fluida which gives 
origin to the peculiarly nauseating odor characteristic of the disease. 
Generally a reddish and infiltrated, more or less annular patch sur- 
rounds the umbilical depression, which may be filled with crusts. 
Syphilodermata, pediculosis, and scabies in women are to be care- 
fully excluded in the diagnosis. 

Treatment- — Liquor sodas ehlorinatae, carbolic acid solutions, and, 
in chronic cases, iodized phenol will be required in its management. 
The dressing of the navel in the newborn infant, the improperly ad- 
justed apparatus for retention of an umbilical hernia, and the 
corsets or " uterine supporters " of women, should not be permitted 
h> occasion or aggravate the disease. 

Eczema Crurum (Eczema Crurale). — Upon the legs, where the 
force of gravity is more potent than in other parts of the body, aggra- 
vated forms of eczema are found complicated with varicose veins and 
oedema, with dense infiltrations and indurations. In ancient cases the 
frequent elephantiasic aspect is significant, one limb being several 
inches larger in circumference than its fellow. The skin is covered 
from knee to ankle with enormous patches of eczema rubrum of an in- 
tensely angry appearance, moist and crust-covered; or is dry, glazed, 
and of a lurid, reddish hue; or is dry, horny, and ridged with irregu- 
lar projections surmounted by scales resembling the rough bark of a 
tree : or, again, with or without oedema, the integument is tense, in- 
elastic, seamed with scars of old varicose ulcers, and deeply and 
irregularly pigmented, a condition with some difficulty distinguished 
from syphilitic ulceration of the same region. At its onset eczema 
of these parts may assume any one of its known forms. In infants 
in long clothing, where the lower extremities are subjected to a higher 
temperature than in adults, the vesicular and pustular forms are 
common. The exceedingly obstinate forms of eczema of the legs, 
especially those complicated with varicose veins, are, of course, 
chiefly encountered in middle life and .in advanced years. 

Diagnosis. — The diagnosis is. in general, to be established by con- 
sidering the points heretofore discussed. The chief difficulty lies in 
distinguishing the eczema associated with ancient varicose cicatrices 
of the leg from syphilitic scars of the same locality that have resulted 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 



243 



from degenerating tubercular syphilodermata or from gummata. In 
some cases, when no distinct history can be obtained, there will be a 
doubt, since the force of gravity upon the vessels, even without vari- 
cosities, produces certain common features, notably deep pigmenta- 
tion, in both classes of cases. In women the sexual history is all- 
important, including the order of succession of abortions, miscarriages, 
and viable infants. In both sexes the discovery of other lesions, and 
especially of characteristic cicatrices elsewhere, must be attempted. 

Fig. 45. 




Eczema of the legs. 



It will be remembered that the syphilitic ulcer tends to the shape of a. 
circle or a segment of a circle, and though occasionally existing as the 
sole lesion upon one leg, it is frequently multiple, or may involve 
both extremities, the pigmentation in old cases occurring chiefly at 
the periphery of the scar. Very extensive pigmentation about ancient 
cicatrices, especially disposed between irregularly defined scars, is 
commoner in eczematous forms, as the pigmentation due to syphilis 
though long-lived is yet the more ephemeral. With periosteal nodes 
the diagnosis is clear. 

Treatment. — The treatment of eczema of the legs does not differ 
from that of eczema in general, except as regards the indications to 
be met relative to the support of the parts, thus counteracting the 
effect of gravity. In severe cases rest with the foot elevated and the 
leg placed in the horizontal position should be maintained, and other 
indications met by the use of the various liniments, lotions, and oint- 
ments already described. For those who must pursue their accus- 
tomed occupations the problem is difficult. An excellent preparation 



244 RYPEEMMIAS AND INFLAMMATIONS. 

for subacute and chronic cases is found in the glycogelatins (q. v.), 
as they furnish not only protection, but also some support. More- 
over, they frequently may be left in position for a week at a time. 
As a rule, they are not indicated in acute cases or where there 
is much discharge; yet in some of these cases they are well tolerated 
and do good. From 1 to 3 per cent, of ichthyol, thiol, or salicylic 
acid in most cases may be added to the glycogelatin with advantage. 
A dressing well adapted to the larger number of cases of eczema 
of the lower limbs is disinfection of the surface and the application of 
the Lassar paste or other well-selected unguent or paste, followed by 
dusting the whole area with a powder, over which may be neatly 
applied, if desirable, a cheese-cloth bandage. Often, however, this 
bandage may be dispensed with, as in both sexes a woman's long 
stocking, made light and thin, such as is used in the summer season 
and always of white or undyed cotton, may be drawn over the limb. 
Over this stocking may be wound, for the purpose of support, either 
a flannel bandage cut on the bias, which can, as a rule, be applied 
without especial skill by the inexpert, or in chronic cases that will 
tolerate it an elastic bandage, the inner white stocking being changed 
with each dressing. In the case of male patients it is often desirable 
that the man's " sock " be drawn over the long white stocking below. 
In this way support without compression (which is the essential 
point) may be secured. 

A favorite dressing in dry, papular, erythematous, and squamous 
patches of the disease is applied as follows: the parts are bullied 
with hot borated water for several minutes until the itching is re- 
lieved, and then are carefully and thoroughly dried. The patch is 
then completely covered with a dusting-powder, which, according to 
the indications of the case, is either emollient, astringent, or stimu- 
lating. Finely powdered tannin with French chalk, or boric acid 
and starch, or bismuth snbnitrate, zinc, and starch may thus be used. 
Strips of cheese-cloth are superimposed. A snng-fitting rubber or 
flannel bandage cut on the bias encompasses the whole. The dressing 
is left in situ as long as it is comfortable, often for two or three days, 
when it can be removed. In properly selected eases the itching is 
relieved, the infiltration is reduced, and the patch soon loses its hyper- 
semic aspect. Occasionally no other treatment will be required. 

Eczema of the Hands and the Feet (Eczema Manuum, Eczema 
Pedum). — No more striking illustration of the significance of the 
etiology of eczema can be adduced than that to be discovered in the 
hands. With these organs man toils to earn his bread, and the eczema 
they display is their protest against the rude contacts which are thus 
necessitated. Unfortunately, in too many patients the imperative 
necessity of bread-winning forbids consent to the best methods of 
relief, viz., temporary disuse of these organs. The feet may be 
similarly attacked, and for similar reasons. A broken down trans- 
verse arch of the foot is cited by Ruggles as a cause of eczema in this 
region. 1 All forms of eczema are here seen — erythematous, vesicu- 
1 J. C. D., 1909, xxvii., pp. 105-111. 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 



245 



lar, papular, pustular, and squamous — involving the entire surface, 
or limited to the wrists, ankles, interdigital spaces, palmar or plantar 
surfaces, or one or more digits of either hand or foot. The motions 
of the part are so free that fissures are common and often are exceed- 
ingly painful. The itching may be severe, and parts of one hand 
or of one foot may be extensively rubbed, torn, or abraded by the 
other. Vesicles are frequently encountered upon delicate portions of 
the skin, as over the dorsum and interdigital spaces, while in the 
denser palm and sole such lesions are deep seated and do not tend to 
spontaneous rupture, but on puncture a clear serous or a cloudy fluid 
may be evacuated. 

Fig. 46. 




Eczema flssum (Fox). 



Palmar and Plantar Eczema is commonly asymmetrical, but may 
be symmetrical. The hands are more often involved than the feet. 
The condition is characterized by the appearance of irregular, ill- 
defined, more or less diffuse areas of dry, dead-whitish, or hypersemic, 
indurated, and thickened integument, which may be fissured or which 
may produce such a tense inelasticity of the surface that the digits are 
semiflexed into the palm or sole. 

Circumscribed patches of eczema, with fairly defined outline, red- 
dish in color beneath crust or scale, subacute in course, and accom- 
panied by paroxysmal itching, are of common occurrence on the 
dorsum and also on the palm or the sole. In the latter situation they 
may be traversed by one or more painful fissures, the same being true 
of the fingers and the toes. Upon the back of the hand these circum- 
scribed patches are prone to pursue an indolent course, improving 
temporarily under appropriate treatment and becoming aggravated by 
every exposure to the causes by which they were first induced. 

The long list of etiological factors which may here be efficient can 
scarcely be enumerated. The majority have already been considered 
in discussing the causes of eczema in general. The influence of all 
articles handled in the trades, occupations, and professions, as well 



246 HYPEREMIAS AND INFLAMMATIONS. 

as the action of toxicants and dyes, must be remembered. Thus, 
printers, bakers, and masons suffer in the hands, and the wearers of 
dyed stockings and coarse, ill-fitting shoes and boots suffer in the feet. 
These so-called " Trade Eczemas" are often due wholly to local causes 
and disappear promptly on removal of the latter. Such conditions 
should properly be classed under chronic dermatitis. 

Diagnosis. — In the matter of diagnosis, scabies, dysidrosis, pso- 
riasis, and syphilis have to be considered. In scabies the vesicles are 
firmer, more often unruptured, are fewer, are more isolated and more 
intermingled with crusts, pustules, and even with bullae, which latter 
are rare in eczema. The discovery of the parasite or its burrows and 
a history of contagion will aid in removing doubt. Numerous pustu- 
lar lesions in young subjects are, however, most commonly produced 
by the acarus. The occurrence of the eruption on the body elsewhere 
than on the hand is also to be expected in scabies, with respect to 
which it should be remembered that the burrow may not be visible, 
and that it may be wanting when the parasites are present. In dysi- 
drosis there is usually a history of hyperidrosis of the hands and feet. 
The lesions, which are vesicular at first, becoming pustular later, are 
usually larger, more deeply seated, and less numerous than in eczema ; 
they appear in greatest number upon the digits, in many instances 
not involving the palms or soles ; are less inflammatory and produce a 
sensation of burning rather than itching. Exfoliation in dysidrosis 
leaves a tender epidermis rather than an infiltrated, oozing surface. 
Psoriasis of the palms and soles is almost always accompanied by the 
presence in other parts of the body of patches, the typical characters 
of which should throw light on the local disorder. They are dry, 
non-discharging lesions, very rarely fissured as in eczema of the hands, 
have a distinct contour (which is rare in eczema), and are covered 
with more abundant and more lustrous scales. Eczema is less sharply 
outlined, and occurs in larger and more diffused areas than either 
psoriasis or syphilis. The scaling syphilodermata of the palms and 
soles occur early and late in the disease, and usually after a distinct 
history of infection. The lesions in syphilis are usually isolated, 
firm, deep infiltrations, circular in outline, with very sharp definition, 
and they may be covered with dry, adherent, dirty-white scales, be- 
neath which the brown-and-red hue of the persistent lesion can be dis- 
covered. Superficial or deep circular excavations of tissue, single or 
multiple, with punched or ragged edges, are visible. The eruption is 
rarely, like eczema, accompanied by itching or by discharge, but 
painful fissures may form. It occasionally affects the dorsum of the 
hand or the foot, favorite sites of eczema manuum, but almost in- 
variably it has in such cases swept thither from the palm or from 
the sole. 

In both syphilis and eczema of the hand the right organ in right- 
handed toilers is usually most involved, even where there is apparent 
symmetry of distribution of lesions. 

Treatment. — The treatment demands, first, rest for the organs and 



TOPICAL AND SPECIAL VARIETIES OF ECZEMA. 247 

a simultaneous discontinuance of the exciting cause. In the trades 
the result of the latter can usually be demonstrated by the patient, 
who notices the difference between the condition of the skin on Mon- 
day morning after a Sunday's rest and that which was distressing 
on the preceding Saturday night. When practicable, protection dur- 
ing labor must be secured by the use of gloves, neatly applied finger- 
cots, rubber-stalls, or bandages, retaining a dressing to the part of the 
hand or the foot that is the seat of the disease. For circumscribed, 
non-discharging patches on the dorsum of the hand or the foot the 
dressing described in connection with eczema of the extremities may 
be applied. When the nature of the labor performed is such as to 
render it impossible to secure protection of the hands or fingers in 
this way, something may be accomplished in a few cases by directing 
that the hand be frequently dipped in a protective solution or pow- 
dered during the hours of labor. Thus, printers may dust their 
fingers with lycopodium, and individuals compelled to retain their 
hands in irritating solutions can anoint these organs occasionally 
with an oily or fatty substance. Generally it may be said that ec- 
zematous hands are too frequently brought in contact with water; 
the ill effects of this are made evident not only in laundresses, but 
also in those who personally must attend to the ordinary duties of 
the household. For cleansing the hands oatmeal water may be 
used and after each washing they should immediately be covered 
with a suitable dressing, or with a simple lotion, ointment, or powder. 
For protection of the hands and for the retention of dressings the 
cheap white cotton gloves such as are worn by infantrymen are con- 
venient and serviceable. They should be large enough to go on 
over the dressings easily and should be washed as soon as soiled. 
For mild cases equal parts of tincture of benzoin, glycerin, and alcohol 
diluted more or less with water make a serviceable and agreeable 
application. When extensively and acutely involved the hand should 
be dressed with care, each finger being separately wrapped in gauze 
which has been soaked in a lotion or oil or has been spread with 
the selected ointment or paste, and the whole covered with a bandage 
or other dressing. 

The local application must be chosen in accordance with the prin- 
ciples previously given for the treatment of eczema in general. In 
subacute and chronic types tarry compounds are very useful, and 
caustics more than ever needful when there are fissures. The fissures 
may often with advantage be painted with compound tincture of 
benzoin. Protective flexile collodion plays an admirable part about 
the finger-nails where irritable seams and fissures form with over- 
hanging fringes of torn and ragged epidermis, bordered with red. In 
painful eczemas of this region the immersion, particularly at night, 
of the entire hand or the foot in hot borated water may be practised, 
followed by careful drying and dressing with the selected application. 
When the epidermis of the palm is greatly thickened it should be 
shampooed at night with green soap, pure or in spirit, with the aid 



248 HYPEREMIAS AND INFLAMMATIONS. 

of hot water, followed by a salicylated soap-plaster or by a salve con- 
taining white precipitate, 10 to 20 grains to the ounce (0.66-1.33 
to 30.), or some preparation of tar. For intractable cases caustic 
potash, in the strength of 20 to 30 per cent, solutions, can be mopped 
well into the thickened palm and be followed by a salve application. 
Crocker suggests the application of dressings moistened with a solu- 
tion of pancreatin or papain to the areas of thickened epidermis, 
the purpose being to soften the cells by digestion. 

A paste useful in many mild cases and one which dries rapidly is 
made of 10 parts each of glycerin, dextrin, and water. To this may 
be added from 1 to 3 per cent, of thiol or ichthyol. The ingredients 
are mixed on a hot water-bath and form a sort of liniment, whieh 
may be painted on the skin. Unna's litharge-glycerin-starch paste, 
described on a preceding page, is also a valuable and effective prep- 
aration for subacute cases. For chronic, sluggish eczema of the palm 
Duhring recommends an ointment composed of equal parts of mer- 
curous nitrate, plumbic acetate, and zinc oxide ointments. 

Radiotherapy has given excellent results in a number of these 
cases, the technique being that employed in the treatment of psoriasis. 

For the fingers and hands Unna's mull-plasters, but only if freshly 
imported, fill every requirement. These plasters may be cut into 
strips and be applied with neatness to every digit. Zinc-oxide, sali- 
cylic acid, tar, and ichthyol mulls are all available for this purpose. 

The condition known as chapping of the hands and face is, prop- 
erly speaking, a dermatitis, since it is usually dependent upon ex- 
posure to wind and weather and disappears when the cause is re- 
moved. It sometimes occurs, however, as a condition indistinguish- 
able clinically from mild eczema of this region. In those sub- 
ject to this disorder care should be taken through the changeable 
weather of spring and autumn not to expose the skin to cold or wind, 
especially if the hands have been previously immersed in water and 
are not perfectly dry. In many instances the mischief can be pre- 
vented by a simple oiling of the skin after each washing, or instead 
of oil equal parts of tincture of benzoin, glycerin, and alcohol may 
be used. This last preparation is not only a preventive, but it often 
affords relief in mild cases. Severer forms should be treated as 
corresponding grades of dermatitis or of eczema. 

Eczema as it Affects the Nails (Eczema Unguium). — For de- 
scription of this affection see the section devoted to diseases of the 
nails. 

Eczema of the Tropics (Prickly Heat). (Eczema Solare, Lichen 
Tropicus, Miliaria Rubra, etc.) — For description of this disorder 
see the chapter devoted to tropical diseases. 

Universal Eczema. — Patients thus affected should be treated in 
bed. The diet, which is of great importance, should be of unstim- 
ulating quality; but it is not to be forgotten that in a disease in- 
volving the entire surface of the body the strength is sooner or later 
liable to be exhausted, and a supporting dietary, even ferruginous 
tonics, is often required. 



PLATE III 




Traumatic Dermatitis Consecutive to Pruritus Cutaneous. 



DERMATITIS. 249 

The local treatment is by alkaline and bran-baths, followed by 
lime-water-and-oil lotions, a dusting powder, ointment, or other 
dressing suited to the local condition. In treating universal eczema 
the entire surface does not usually require the same topical agents. 
Often there should be cold-cream salve, freshly made, for the eyelids ; 
a dusting-powder for the non-discharging or scaling surface ; a salve 
or an oleated lotion for discharging surfaces of the integument; 
and special dressings for the extremities, the ears, the hands, etc. 

DERMATITIS. 

(Ger., Hautentzundung- ; Fr., Dekmatite, Dekmite.) 

Inflammation of the skin occurs in a large number of cutaneous 
affections. Under dermatitis, however, are grouped those inflamma- 
tions only in which the result is plainly due to a direct influence 
exerted upon the skin by thermal, chemical, or mechanical agencies. 
The inflammatory process may involve the superficial or the deep por- 
tion of the integument, or it may extend to the subcutaneous tissues, 
and even deeper. The symptoms vary with the nature of the cause, 
the extent and degree of its influence, and the circumstances at- 
tending its operation. There may be simple hyperemia and oedema 
of a few hours' duration, or there may follow papules, vesicles, bullse, 
pustules, and crusts. These lesions may be situated on an intensely 
reddened and much swollen base. In severe cases ulceration, gan- 
grene, and extensive scarring may occur. With these phenomena 
there may be general symptoms of mild or of severe grade, due to 
the influence exerted by the local process upon the general economy. 
When the exciting cause is of moderate intensity but is long con- 
tinued there results a chronic dermatitis in which the skin may be 
more or less thickened and infiltrated, dull red in color, and cov- 
ered with fine adherent scales. 



DERMATITIS TRAUMATICA. 

External violence, varying in character and severity, is capable 
of inducing dermatitis, the symptoms of which differ in degree, 
though their career is, in general, the same. In this list are included 
the inflammations produced by surgical interference with the con- 
tinuity of the integument ; excoriations caused by scratching, by fric- 
tion with garments and other articles injuriously acting upon the 
skin; by the various implements handled in the trades; and by the 
bites or the stings of beasts, insects, reptiles, and fishes, when the 
result is traumatic and not toxic in character. These injuries may 
be in the form of contusion, blow, concussion, pressure, puncture, 
incision, or laceration, and the consequences be declared in heat, 



250 HYPEREMIAS AND INFLAMMATIONS. 

swelling, redness, and pain; in itching, burning, stinging, or prick- 
ing sensations; with subsequent inflammatory symptoms varying 
in grade from mild and transitory hyperemia and exudation to the 
severer grades of inflammation mentioned in the preceding paragraph. 

DERMATITIS VENENATA. 

Certain medicinal and other substances applied to the external 
surface of the skin are capable of exciting inflammation by operating 
either as caustic, irritant, toxic, or even traumatic agents. 

Symptoms. — Careful observation of a typical case of dermatitis 
venenata soon after the onset of symptoms will disclose the exact sur- 
face of contact, such surface being distinctly outlined by a reddened, 
tolerably well-defined line, within the limitation of which will be 
seen a slightly tumefied, erythematous area, at times displaying 

Fig. 47. 




Dermatitis venenata (Fox). 

closely packed, pin-point-sized papules, vesicles, or pustules. As 
the dermatitis progresses it is not necessarily limited to the sur- 
face with which the irritant has come in contact. The inflamma- 
tion may extend to adjacent portions of the skin, or, as a result 
of absorption and consequent toxic effects or of reflex nervous irri- 
tation, it may appear on distant surfaces of the body. Numerous 
types of cutaneous lesions — macules, pustules, papules, vesicles, 
bulla?, wheals, scales, crusts, free serous and purulent discharges, 
subcutaneous abscesses, and even gangrene with sloughing — may 
occur, the result being largely proportioned to the character of the 
agent producing the injury and to the susceptibility of the individual. 

Erythema limited to the region covered by the diaper in infants 
may occur in epidemic form in hospitals or in isolated cases in pri- 
vate families. It is caused by the use of borax and soft-soap in 
washing linen. Sheets and pillow cases may produce the same rash 
on other parts of the body. 

Etiology. — Among the sources of dermatitis venenata may be 
named most of the strong acids and alkalies, croton-oil, cantharides, 
mustard, tartar emetic, mezereon, the salts of mercury, arnica, 
turpentine, ether, chloroform, tarry compounds, resorcin; many of 



DERMATITIS VENENATA. 251 

the dyes, several members of the rhus family (Rhus toxicodendron, 
poison-ivy, and Rhus venenata, poison-sumach), the nettle, the smart- 
weed (Polygonum punctatum), cowhage (Mucuna pruriens), and 
glass in fine powder or in delicate filaments, such as are thrust into 
the skin when handling certain articles of Venetian glassware. This 
list might indefinitely be extended, as there are few articles which 
are not capable of producing some irritation of the surface of the 
skin if applied to it with sufficient vigor and for a certain period of 
time; and in some cases it is difficult to decide whether the effect is 
more traumatic than toxic. An almost equally long list of substances 
of animal origin might be named having poisonous effects upon the 











Fig. 48. 






wm^^&m 
















\ 


■:■■■ 


• 




•Oi 









Dermatitis venenata. 

integument, such as decomposed or ammoniacal urine, feces, ichorous 
pus, and pathologically altered secretions from the uterus, the eye, 
ear, nose, etc. 

A few of the more common causes of dermatitis are : the use of 
soap containing an excess of alkali or even minute particles of bone 
for laundry, toilet, or other domestic purposes, as also several of 
the proprietary articles sold in the shops for similar employment. 
Stockings and other undergarments dyed with anilin, picric acid, 
chromium, or arsenic; hair dyes, the leather lining of the inside of 
the hat or the cap, and the painted toys to which the lips of children 
are applied, will beget mischief in the various regions of contact for 
each. Duhring reports cases in which the dyestuff in the lining 
of shoes penetrated the material of stockings in women, and produced 
dermatitis of the feet or the legs. 

The tincture of arnica, an article much used as a domestic appli- 
cation for contused and incised wounds of a simple character, has pro- 
duced very serious annoyance in some cases, two such having been 
recently presented at the author's clinic. The number of these acci- 
dents is annually increasing. Cartier 1 reports excessive erysipela- 
1 Lyon m§d., April 13, 1884. 



252 HYPEREMIAS AND INFLAMMATIONS. 

tous swelling, a phlyctenular eruption, and submaxillary adenopathy 
resulting from the external use of arnica. Beauvais reported to the 
Paris Medical Society gangrenous results in one case. Buchner be- 
lieves this poisonous action to be due to insects (particularly the 
Atherix maculatus) found in the calyx of the arnica-flower. Other 
native plants, a large number of which are enumerated in a valuable 
monograph and supplemental list by J. C. White, 1 are similarly 

Fig. 49. 




Dermatitis venenata produced by chemicals. 

effective. Wesener, 2 reports that the Malacca bean-tree (Anacar- 
dium orientale) furnishes a caustic oil, called "cardol," or "cardo- 
leum pruriens," that produces, after application to the skin, vesicles 
and vesico-pustules which contain cardol and terminate by crusting. 
He reports a geueralized eruption, beginning on the face, due to this 
cause. 

The antiseptic dressings of modern surgery are at times responsi- 
ble for eruptive disorders. Among these antiseptics may be named 
iodoform, which has produced erythema, vesicles, pustules, and 
wheals. 3 Carbolic-acid and corrosive-sublimate dressings have had 
similar effects. The prolonged application of weak solutions of 

1 Dermatitis Venenata, Boston, 1887; and J. C. D., 1903, xxi., p. 441. 

2 Deutsche Arch. f. klin. Med., xxxvi., p. 578. 

8 See paper of K. W. Taylor, read before the New York Academy of Medicine 
1887. 



DERMATITIS VENENATA. 253 

carbolic acid is followed occasionally by gangrene. 1 Formalin causes 
vesicular and pustular lesions of the fingers in predisposed individ- 
uals. Orthoform may give rise to lesions similar to those caused by 
iodoform, with the occasional production of gangrene. 2 Many of 

Fig. 50. 




Rhus radicans: leaf one-half natural size (Culbreth). 



the articles employed therapeutically by the dermatologist should be 
placed in the same category. Green, 3 of London, reports oedema 
of the skin followed by desquamation, resulting from the application 
to it of the ointment of ammoniated mercury in the strength of 2 
drachms (8.) to the ounce (30.). 

Leszinsky reports a case of dermatitis of the face following the 
use of a "triple extract of heliotrope" as a toilet-preparation. 

An exceedingly common source of dermatitis is urine retained 
upon underclothing of adults. A persistent dermatitis of the scro- 
tum, the perineum, or the inner faces of the thighs in either sex, 
always calls for examination as to whether a few drops of urine are 
not left in contact with such underclothing after each act of micturi- 
tion. Fistula?, urinary incontinence, prostatic disease, " stammering 

1 Harrington, Amer. Jour. Med. Sci., 1900, cxix., p. 1, report of 18 cases and 
review of 118 cases from literature. 

2 Dubreuilh, La Presse med., 1901, liii., p. 233. 
8 Brit. Med. Jour., 1884, i., p. 853. 



254 HYPEREMIAS AND INFLAMMATIONS. 

of the bladder," imperfect finish of the coup de piston in men, espe- 
cially after a gonorrhoea and similar troubles, are all to be remem- 
bered. 

The eruption produced by the Poison-ivy and other varieties of 
rhus is almost exclusively an American disease; and from its fre- 
quency in the United States has attracted a great deal of attention. 
A certain degree of susceptibility to the poisonous action of the plant 
is requisite for the production of its effects, as some individuals 
can handle the leaves of the plant with impunity, while others, it is 
claimed, are affected by its exhalations within a circle having a 
radius of several feet. It is, however, difficult to demonstrate the 
truth of the last statement, suspecting, as one may, that such instances 
may be cases of contact with other than the suspected plant. The 
parts commonly affected are the hands and the regions to which 
the latter are carried, such as the face, the genitals, the arms, the 
thighs, and the neck ; barefoot children suffer in the feet and the 
legs. Usually the symptoms are developed in the course of a few 
hours, and they consist of erythematous patches ; scanty or profuse 
vesiculation with abundant serous weeping after rupture of the 
lesions; swelling, oedema, and disfigurement; and intense burning 
and itching sensations. Serious effects are occasionally produced. 
Deeply attached scars may result from subcutaneous abscesses of 
parts greatly swollen. Occasionally in particularly sensitive skins 
the eruption spreads from the skin-surface affected by the poison 
to that where presumably none has been applied. It should be re- 
membered, however, that articles of clothing may for brief periods 
of time furnish sources of further trouble, being worn at the moment 
of contact with the plant, then laid aside, and, the occasion quite 
forgotten, being subsequently employed. Thus, a pair of undressed- 
kid gloves after lying for two weeks untouched have sufficed to 
awaken the disease. 

A number of cases of dermatitis have originated in some parts of 
the Orient from contact with the varnish employed in the finishing 
of lacquered ware. This lacquer is manufactured from a rhus var- 
nish. A few instances of such dermatitis have occurred in America 
from handling newly imported articles of this class. 

Diagnosis.- — An acute dermatitis appearing suddenly on regions 
of the body readily exposed to toxic agents should always arouse 
suspicion of dermatitis venenata. A history of contact with some 
irritating substance can usually be obtained. The inflammation 
in the beginning is limited to the areas with which the toxic agent 
came in contact, is often asymmetrical, and has no relation to the gen- 
eral health of the patient. The process often reaches the point 
of greatest intensity within a day or two after its first manifestations, 
and subsides soon after removal of the cause. 

The peculiar features of ivy-poisoning have been described in a 
monograph on the subject by White, of Boston. 1 According to this 

1 New York : D. Appleton & Co., 1878, from the March number of N. Y. Med. 
Jour, of the same vear. 



DEEMATITIS VENENATA. 255 

author, the lateral surfaces of the digits first exhibit the symptoms of 
the eruption, later the dorsal surfaces, and latest the thickened palms. 
The efflorescence also is more irregularly distributed, more uniformly 
vesicular, and the vesicles are less transparent than in eczema. The 
lesions, moreover, are more vesicular and less papular at the outset, 
and, though suggesting papules by their situation in the palm, are 
in that situation readily made to exude serum by puncture with a 
needle. 

Treatment. — Internal medication is not required. The local 
treatment is that of acute eczema. Black-wash (preferably dilute), 
solution of sugar of lead, or oleated lime-water may be employed at 
first, and be followed later by dusting powders. In two instances 
under our observation a dermatitis due to formalin, and which had 
resisted other treatment for months, yielded readily to radiotherapy. 
A number of other cases due to unrecognized agencies have responded 
equally well to this treatment. (For technique, see Psoriasis.) 

In ivy-poisoning the application of an alkali, for the purpose of 
neutralizing the poisonous volatile alkaloid in the leaves of the plant 
(toxicodendric acid, Maisch), should evidently be considered solely 
with a view to prophylaxis, as it is difficult to understand how such 
neutralization can control the inflammatory process after its onset. 
An ointment made by incorporating a decoction of the inner bark 
of the American spice-bush (Benzoin odoriferum) with cold-cream 
salve affords prompt relief in cases in which it is employed, the diffi- 
culty lying in securing the bark of the shrub in its young and tender 
state. 

Many topical remedies have been vaunted as specifics for the re- 
lief of this disorder, from the brine of a pork-barrel to a decoction of 
the leaves of the plant itself. As the eruption usually subsides when 
the skin is protected and not irritated by the local treatment, it is not 
difficult to explain the result in most cases, though it is possible there 
is a parasitic or toxic element in the poison. Complete covering 
of the affected area with flexible collodion frequently is effective, and 
if applied to the lesions when they first appear often will abort the 
disease. In later stages, care should be taken in opening the vesicles 
to prevent their contents from coming in contact with unaffected 
areas of the skin. After emptying the vesicles with a sterile needle, 
the involved areas may be painted several times with a 50 per cent, 
solution of ichthyol, and when dry covered with a dusting-powder and 
light bandage. Sodium hyposulphite, 1 drachm (4.) to the ounce 
(30.), often gives good results when applied as described above or 
as a wet dressing. Corrosive-sublimate lotions ; saturated solution of 
boric acid; Carron oil; tincture of iron; bromine, 15 drops (1.) to the 
ounce (30.) of olive-oil (Brown) ; dilute nitric acid; sodium bicar- 
bonate; saturated solution of potassium chlorate; and grindelia 
robusta, 1 drachm (4.) of the fluid extract to 8 ounces (240.) of 
water, have each been found useful. 



256 HYPEREMIAS AND INFLAMMATIONS. 



DERMATITIS CALORICA. 

Burns. — A burn is a destruction of the skin by heat or chemical 
action for the relief of which all dead tissues must be separated from 
the living and repair effected by the formation of scar-tissue or the 
growth of new skin. Even where there is simply an erythema with 
slight inflammatory reaction there is a superficial destruction of 
tissue. The two processes of repair; separation and reproduction, 
proceed pari passu. 

Rays of heat and heated objects at a temperature from 125° to 
175° F. produce immediately, or after a brief interval, first, an 
erythema, which disappears when the source of the heat is removed ; 
second, after more prolonged exposure, the symptoms of active in- 
flammation and exudation. Vesicles or bulla?, isolated or con- 
fluent according to the severity of the cause, may rise from a red- 
dened skin which is usually intensely painful. These lesions are 
persistent or are transitory, and are generally filled with a clear 
sen mi, which exudes and dries into crusts after rupture of the 
chamber in which it was imprisoned. At other times the exuda- 
tion is so abundant that the epidermis rises in broad plates, from 
beneath which the serum is exuded. This process may terminate by 
a free production of pus upon the surface and gradual resolution. 
Adenopathy is a frequent concomitant symptom. In such dermatitis 
of extensive areas of the skin the intensity of the process may 
awaken a violent fever, or death may result from shock or exhaustion. 

In yet severer grades there is the production of an eschar, which 
is dry, brown, blackish, and destitute of all signs of vitality; or as 
Kaposi describes it, is dense, coriaceous, and white as alabaster, 
though upon the eschar some vesicles appear, and by their presence 
suggest a false conclusion as to the vitality of the tissues upon which 
they rest. In from eight to ten days the slough is removed by sup- 
purative processes leaving a granulating surface which bleeds readily 
when touched; it is frequently studded with pin-head-sized, white 
islands which are points of regenerated epithelium budding from 
partly destroyed cutaneous glands. These islands of epithelium 
extend and coalesce effecting the repair of extensive areas. In such 
cases the scar which results may consist of penny-sized circular areas 
of normal integument representing these islands, interspersed with 
scar-tissue. If the destruction of tissue is deeper granulation and 
the production of deforming, contracting scar-tissue results. The 
characteristics of the scar thus produced are: its great irregularity, 
its tendency to stellate radiation, and the production of ridges, folds, 
pockets, and bridles. 

Burns involving one-third the body-surface are of grave portent, 
and those affecting one-half the body are generally fatal, even though 
for from twenty-four to forty-eight hours there may be little com- 
plaint of pain. The causes of death in these fatal cases are generally 
obscure, as the post-mortem results are usually negative. Gastric 



DERMATITIS CONGELATIONIS. 257 

and duodenal ulceration, however, is often recognized. Overheating 
of the blood, heart-paralysis, oligocythemia, and actual destruction 
of leucocytes have all been supposed to be effective in bringing about 
dissolution. In cases in which life is prolonged to the third day the 
complications of pyaemia, erysipelas, and tetanus may arise. Lastly, 
exhaustion following fever, suppuration, hemorrhage, and visceral 
affections may lead to fatal results. 

Treatment. — In the treatment of the simplest burns, rest, lotions 
of lead-water, and cool water, with the application of compresses, are 
usually sufficient to secure relief ; occasionally, dusting-powders may 
advantageously be substituted. In the cases in which serum is 
brought rapidly to the surface, with the production of vesicles and 
bulla?, the latter should be punctured skilfully to give relief to the 
tension by the evacuation of their contents, but the roof-wall should 
be preserved, as it may subsequently form an attachment to the ex- 
posed derma beneath. For the relief of the severe pain experienced 
immediately after the burn the use of carron oil and bandaging the 
part had best be employed. Where the burn is sufficiently extensive 
to confine the patient to bed the open air treatment may be employed 
to advantage. Continuous immersion in water having the tempera- 
ture most agreeable to the patient, as practised by Hebra in cases 
of severe and extensive burning, produces a speedy and certain ame- 
lioration of the pain and a favorable condition of the wounds, though 
it does not avert a fatal issue in any dangerous case. 

The strictest antiseptic precautions are demanded when the sup- 
purative process in the skin is both active and extensive. In some 
cases disinfection with a 5 per cent, solution of carbolic acid, or a 2 
per cent, resorcin solution, should be followed by the application of 
protective silk wet with a 5 per cent, solution of sodic biborate or 
bicarbonate, and the whole enveloped either in borax-lint, antiseptic 
(mercuric iodide) wool, carbolized gauze, or salicylated cotton; over 
all, impermeable rubber tissue should be wrapped. Instead of the 
protective silk, it is often better to use strips of sterile moist rubber 
tissue, \ of an inch wide. These are laid smoothly and evenly over 
the surface with narrow spaces between each. The first layer then is 
crossed by a second at right angles to the first. The surface is thus 
practically covered with the rubber tissue, leaving, however, at each 
crossing of the strips small openings for the escape of secretion. 
Boric acid water, or other feebly antiseptic solutions, may then be 
applied and changed as often as necessary without damage to the 
surface beneath. 

Skin-grafting may be required to cover the extensive ulcers left 
by the larger burns. 

DERMATITIS CONGELATIONIS. 

Congelatio, . or dermatitis from congelation, presents usually in 
the milder forms circumscribed erythematous patches or plaques, gen- 
erally recognized under the name of Pernio, or chilblain^ seated upon 

17 



258 HYPEREMIAS AND INFLAMMATIONS. 

the digits or, more rarely, upon the face, and occasioning a disagree- 
able sensation of heat, smarting, or itching, especially after the chilled 
part has been warmed. 1 Chilblains are bluish or purplish red in 
color, and are often seated on a slightly cEdematous integument. They 
are generally cool to the touch when subjectively hot. Authors have 
claimed that anaemia is a chief predisposing cause of the complaint, 
but it frequently occurs in perfectly healthy young people. Sir 
Erasmus Wilson has suggested that some cases of so-called "lupus 
erythematosus " of the hands belong to this category. 

In the second grade of inflammatory reaction, following the state 
of contracted blood-vessels and pallid integument produced immedi- 
ately by the action of cold, bullae and vesicles form, with underlying 
ulcers in severe cases. 

In the third grade gangrene may occur, with and without the for- 
mation of bulla?. The frozen part may become insensitive, white, and 
cold, without the circulation in it of blood- and lymph-currents. From 
this condition reaction occurs, with the formation of an eschar, differ- 
ing after the death of the patient according to the severity of exposure 
to cold. If, however, beside the interference with the circulation, the 
tissue itself has been destroyed, when reaction occurs the part falls 
at once into gangrene ; or there form bullae larger than those described 
above, filled with sanguinolent serum ; or the skin is smooth, marbled 
with bluish lines, whitish, cold, and insensitive. Mortification en- 
sues, followed by the well-known phenomena of the " line of demarca- 
tion," and, in favorable issues, suppurative separation of the dead 
part, granulation, repair, and cicatrization. As the injuries induced 
by congelation are more frequent upon the extremities, the bones, 
especially those of the digits, largely participate in the losses of tissue. 
Septicaemia and a fatal result may follow. 

Treatment. — Chilblains are treated internally by the ferruginous 
tonics, particularly the tincture of iron, externally by stimulant ap- 
plications, such as those containing iodine, camphor, carbolic acid, 
tincture of benzoin, and balsam of Peru. Kaposi recommends : 



Pulv. camphorae, gr. x; 

Cretae prseparat., 3J 5 ^0 

01. lini, f§ij; 60 

Balsam. Peruvian., Tn,xx; 1 



33 M. 



Frictions, with or without medication, are generally useful. The 
parts are to be carefully protected from pressure and undue friction- 
effects. 

Painting the part frequently with a 50 per cent, aqueous solution 
of ichthyol, or the application of an ointment containing 2 drachms 
(8.) of ichthyol to the ounce (30.) gives good results in many cases. 

Dilute nitric acid and peppermint-water in equal proportions, 
painted over the part for three or four successive days, have been 
recommended by Lapatin for the treatment of frost-bitten fingers and 
1 Consult the chapter devoted to the Ervthemata, 



DERMATITIS MEDICAMENTOSA. 259 

toes. Hydrochloric and pyroligneous acids, lemon- juice, 50 per cent, 
and stronger solutions of lead acetate, both in lotions and poultices, 
are also recommended. Meurisse advises in the management of both 
severe ambustio and congelatio that goldbeater's skin be employed 
over any salves or lotions applied to the affected surface. 

In cases of severe congelation the circulation is to be cautiously 
restored by friction performed in an apartment the air of which is 
cool, to prevent too energetic reaction. Friction with snow is em- 
ployed with safety in America and on the steppes of Russia, where 
these accidents are frequent and are grave in results. Perseverance 
for hours in this course is often rewarded with success in apparently 
desperate cases. Antiseptic dressings are usually demanded when 
sloughing and ulceration ensue. 

DERMATITIS MEDICAMENTOSA. 

(Dbtjo Eruptions. Qer., Arzneiexantheme ; Fr., Eruptions 

MEDICAMENTEUSES. ) 

The importance of recognizing the fact that a given eruption is 
produced by an ingested drug can scarcely be overestimated from the 
point of view of the diagnostician. The errors committed in this con- 
nection are so frequent and so annoying to the patient that it is neces- 
sary for the physician to inquire very carefully, before treating any 
cutaneous disease, as to the medicaments previously swallowed by the 
patient, and also to be prompt to connect any aggravation of a cutane- 
ous disease with remedies ordered by himself for internal use. The 
following is but an imperfect list of the drugs the internal adminis- 
tration of which may be followed by an exanthem — imperfect, because 
without question many have yet to be recognized as possessing such an 
action. As to the modus operandi of such medicinal agents, for the 
most part our knowledge on this subject is purely conjectural. Some, 
for example potassium iodide, are eliminated in part by the glands of 
the skin, and presumably have thus a local effect upon such emunc- 
tories ; others, and in this class, probably, should be included quinine, 
induce an urticaria scarcely to be distinguished from an urticaria ah 
ingestis. Some operate, possibly, in either or both ways at different 
times or in different individuals. The absurdity of supposing that 
any disease can be " driven out " by the ingestion of such drugs should 
be relegated to the specious ignorance which first framed such an 
hypothesis. 1 

Acids capable of producing macules, papules, erythema, desquama- 
tion, etc., are carbolic, nitric, tannic, benzoic (and sodium benzoate), 
and boric (and sodium borate). 

Aconite is said to be productive at certain times of marked diapho- 
resis with the occurrence of vesiculation and considerable itching. 

1 For full details and bibligraphy of this subject, consult the treatise on Drug- 
eruptions, by Prince A. Morrow, New York, 1887: and chapter by Ehrmann in 
Mracek's Handbuch, vol. L, p. 639, 



260 HYPEREMIAS AND INFLAMMATIONS. 

The diaphoresis in an irritable skin may be responsible for the 
trouble. 

Antifebrin and Acetanilid occasionally produce an erythematous or 
maculo-papular exanthem, or, when long continued, may cause partial 
cyanosis. 

Antipyrin and Other Remedies of its Class (manufactured by the 
action of glacial acetic acid upon the petroleum-products). — Ernst 1 
has been followed by many observers in recording rashes resulting 
from the administration of antipyrin. The symptoms arc discrete 
and confluent patches of bright-red, scarlatiniform, erythematous, 
and pruritic macules or papules. Veiel 2 reports cedema with bulla; 
upon the lips and toes, and over the palate, with urticarial lesions of 
the palms and soles, after ingestion of antipyrin. Brock, Darier, 
and others have reported cases in which antipyrin has produced a 
more or less persistent erythema in the form of isolated, scattered, 
sharply defined plaques. These plaques are usually few in number, 
and they tend to return in the same sites whenever the susceptible 
individual ingests the drug. The redness and pigmentation may per- 
sist for several weeks. Wickham reports an antipyrin-rash which 
simulated perfectly a macular syphiloderm. 3 

Antitoxin. — (See Serum Eruptions.) 

Arsenic. 4 — Erythematous, vesicular, papular, and much more 
rarely pustular, bullous, and ulcerative lesions occur upon the face, 
the back, and the hands after the ingestion of arsenic. The well- 
known effects of the administration of Ihe drug in toxic doses upon 
the mucous membranes of the eyes, nose, and mouth need not be de- 
scribed in this connection, nor yet the grave gangrenous symptoms, 
with osseous necrosis, that have been observed in workers in the 
metal. 

A bright-red, scarlatiniform blush with a few isolated vesicles has 
covered both shoulders of a young woman with a delicate skin after 
taking three medicinal doses of Fowler's solution, the eruption being 
present but less distinct upon her face and hands. In two cases the 
rash in polymorphic type was limited to the hands alone. 

Young patients who have taken arsenic in the largest medicinal 
doses for relief of chorea often present as a result a dark discoloration 
chiefly of the skin of the chest and the neck, but also of other parts of 
the body. This discoloration is suggestive of the bronzing seen in 
Addison's disease. In some instances there are no other cutaneous 
symptoms. Guaita and Liege noted these phenomena usually in the 
fifth month after ingestion of the drug. 5 

Long-continued use of arsenic may produce keratosis of the palms 

1 Centralb. f . klin. Med., 1885. 

2 Archiv, 1891, xxiii., p. 33. 

3 Cf. Berliner Monatshefte, 1902, xxxv., p. 137 (with review of literature). 

4 Cf. Brooke-Boberts, ' ' The Action of Arsenic on the Skin as Observed in the 
Recent Epidemic of Arsenical Beer-poisoning," B. J. D., 1901, xiii., p. 121. 

& Cf. Hamburger. "Arsenical Pigmentation and Keratosis," Johns Hopkins 
Hosp. Bull., 1900, si., p. 87, 



DERMATITIS MEDICAMENTOSA. 



261 



and soles of a severe grade, obstinate character, and occasionally grave 
results. Administered for relief of psoriasis, the resulting keratoses 
have later developed into epitheliomata of malignant type. 1 



1 Hj 


•jHffiK^ m 


r 


h 


ML , 




1 


^Se$u& - 


K . 


SF^ 


HP 


ESSfttv' 1 




■ '^BvV'J 




1 


Hi' : ^Hi 


■MS 


m . H 





Generalized pigmentation and keratosis following long-continued use of arsenic. 



By far the largest number of rashes are, however, produced in per- 
sons previously suffering from the cutaneous disease for the relief of 
which the drug is administered. Here the toxic effect is declared by 
either — first, increased hyperemia of the skin, visible in an erythema- 
tous patch, or beneath the scales of a squamous patch, or as an 
areola of bright-red hue about any aggregation of lesions ; second, by 
simple aggravation of the type of a disease already in existence (re- 
currence of acuity in a subacute eczema) ; third, by rapid peripheral 
extension of a disease which had previously been well limited in 
contour; fourth, by converting a disease exhibiting uniformity of 

•Hartzell, Amer. Jour. Med. Sci., 1899, cxviii., p. 265; and Darier, Annates, 
1902, iii., p. 1126. 



262 HYPEREMIAS AND INFLAMMATIONS. 

lesions into one characterized by multiformity. Each of these results 
might be illustrated by cases. 

In a series of eight cases of poisonous effects produced by arsenical 
paper-hangings, and reported by Brown, 1 there were, curiously, no 
cutaneous symptoms. 

Belladonna, — The well-known erythematous, scarlatiniform, or 
reddish efflorescence produced by belladonna and its alkaloids is usu- 
ally limited to the upper segment of the body, but it may become 
generalized. It is said to occur more frequently in children, prob- 
ably because it has been administered largely to individuals of that 
age under the delusion that it is useful as a prophylactic in scarlatina. 
Very disagreeable and even dangerous results have followed the in- 
stillation into the eye of atropine as a mydriatic, the rash being ac- 
companied by constitutional symptoms. 

Boric Acid. 2 — Erythema, papules, vesicles, bulla?, and lesions re- 
sembling those of erythema multiforme (Fordyce) are reported as 
following the ingestion, or absorption, of boric acid. A mild form 
of acute exfoliative dermatitis, with temporary loss of hair, is re- 
corded as occurring after prolonged use of the remedy. 

Modadewkow reports a case in which the pleura was washed out 
with a 5 per cent, solution of boric acid, a part of which was not 
removed. There occurred as a result an erythematous rash over the 
face, the trunk, and the extremities. 

Bromine and its Compounds. — A full account of the cutaneous ef- 
fects of bromine and its compounds, when administered internal I v. 
is contained in a paper on medicinal eruptions, read in 1880, by 
Van Harlingen, of Philadelphia, before the American Dermatologies] 
Association. Acneiform lesions, pustules, macules, maculo-papules, 
papules, eczemaform moist patches, furuncles, urticarial wheals, 
scales, and ulcers have been induced by swallowing the bromides of 
potassium, sodium, ammonium, and lithium. By far the commonest 
are the acneiform and pustular lesions, occasionally accompanied by 
pruritus, which appear upon the face and the upper portion of the 
trunk, though the rash may be very distinct upon the genital region. 
Duhring reports an interesting observation of a patient in whom the 
eruption simulated closely the maculo-papular syphiloderm, the 
patient having taken a bromine salt for three years. The eruption 
first appeared within five or six days after decreasing the dose. Ka- 
posi observed a case of bromide-rash in a nine-months-old suckling, the 
mother having taken 120 grammes of potassium bromide in two 
months, herself exhibiting no traces of eruption. 

A remarkably characteristic exanthem is produced by the admin- 
istration of potassium bromide, especially to infants and young chil- 
dren. The lesions are condylomaform, quite numerous, conspicuous 
about the face and neck, where they are packed closely together, but 
they are also seen on other parts of the body. The small coin- to 

1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 

2 Cf. Wild, Lancet, 1899, i., p. 23 (with bibliography). 



DEBMATITIS MEDICAMENTOSA. 263 

nut-sized elevated nodules are usually flattened ; and they often resem- 
ble carbuncles, as they have a cribriform summit on which multiple 
points of imprisoned pus are visible. This rash, though rare, has 
been carefully studied and well illustrated by chromo-lithographic 
reproductions. 

T. C. Fox and Gibbes report these condylomaform nodules in the 
case of an infant in which the histology of the lesions was carefully 
studied; and Fay in a child eleven months old also recognized an 
exanthem which had been mistaken for molluscum epitheliale. These 
lesions are somewhat similar to the condylomaform rash seen in chil- 
dren after the administration of potassium iodide. The lesions may 
appear for some weeks after the drug has been discontinued. 

Browse, of Cambridge, England, recommends for relief of these 
symptoms the application of a solution of salicylic acid, 1 grain to the 
ounce (0.066-30.) of water, frequently applied on lint, he having 
successfully treated in this way sores as large as the palm of the 
hand. 

Cannabis Indica — An eruption produced by the ingestion of this 
drug was observed by me in the case of an adult male, who was cov- 
ered extensively with papulo-vesicular lesions after swallowing 1 
grain (0.066) of the extract. 1 

Cantharides. — Erythematous and papular eruptions are reported 
in a few instances. 

Capsicum. — Erythema results occasionally. Allen reports a pap- 
ulo-vesicular eruption following the internal use of the drug. 

Chloral. — An erythematous rash is the commonest of the eruptions 
produced by chloral, though wheals, red and yellowish papules, vesi- 
cles, pustules, and petechial blotches have been observed. The rash 
occurs upon the face, the neck, the trunk, and the limbs, of the latter 
especially on the extensor surfaces. In a man of advanced years 
and totally deaf, who had slept only under the influence of chloral 
for four years, discrete scaly patches as large as saucers covered the 
hands and the lower extremities. 

Martinet 2 reports an erythematous and scarlatiniform rash, occa- 
sionally commingled with urticarial and purpuric lesions, occurring 
upon the face and neck, the front of the chest, the extensor surfaces 
of the larger joints, and the dorsum of the hands and feet. There 
was no pyrexia nor indisposition, but in some cases there were dysp- 
no3a and cardiac palpitation. 

Chloralamid. — Pye-Smith reports a case in which this drug pro- 
duced a scarlatiniform eruption, involving the mucous membranes, 
accompanied by fever, and terminating in free desquamation. 

Chloroform. — During inhalation an erythema of short duration, 
and rarely, purpuric spots are noted. 

Cod-liver Oil. — According to Farquharson, cod-liver oil after being 

1 New York Med. Kecord, May 11, 1878. 
'These de Paris, 1879. 



264 HYPEREMIAS AND INFLAMMATIONS. 

swallowed is capable of producing an acne. This result is traceable 
to the use of inferior qualities of the oil. 

Condurango.. — Guntz 1 reports the occurrence of furuncular and 
acneiform lesions in twenty patients out of one thousand who were 
taking condurango for the relief of syphilis. 

Copaiba and Cubebs. — Occasionally the ingestion of copaiba is fol- 
lowed by a vividly red rash, in the form of discrete macules, more 
rarely maculo-papules, invading chiefly the lower segments of the 
extremities and the skin of the belly, but often completely covering the 
body-surface. The rash may occur in dark mulberry-red petechia}, 
and always is accompanied by pruritus. Inasmuch as the drug often 
is administered for the relief of a venereal disorder not syphilitic, care 
should be taken not to confound the eruption it may excite with the 
early macular syphiloderm. Cubebs is followed much more rarely 
by a similar result. 

Digitalis/ — In liehrend's treatise on Diseases of the Skin 2 refer- 
ence is made to cases in which macular and maculo-papular rashes 
succeeded the ingestion of digitalis. 

Ergot rarely gives rise to vesicles, pustules, small furuncles, or 
petechia?. Circumscribed areas of gangrene on the extremities are 
more common. 

Iodine and Its Compounds.'' Potassium iodide is responsible for 
the larger number of all eruptions among medicinal rashes. The 
frequent employment of this drug and the very marked influence it 
possesses over the skin render the Btudy of these morbid results im- 
portant. Unlike many of the other substances in the list of drugs, the 
iodine compounds are followed by >< -me species of rash in probably the 
larger number of all persons who swallow them. A.8 is true also with 
the bromine compounds, the eruption may persist, or even first appear, 
after the drug lias been discontinued. 

The resulting lesion- may he macular, papular, vesicular, bullous, 
pustular, petechial, multiform, or may be circumscribed subcutaneous 
abscesses. In appearance the rashes produced by iodine and its com- 
pounds may simulate those of every other dermatitis. 

The macular rash is seen best fully developed over the upper 
extremities in discrete erythematous patches or as a diffuse blush. 
Generally the rash is displayed symmetrically. The hands are often 
affected, and suggest in appearance the hands of the anilin-worker. 
The rash assumes at times the papular type with special production 
of papules upon the face. 

Berenguier describes a scarlatiniform rash of sudden occurrence 
with numerous minute discrete vesicles upon the surface of the skin. 
Eczemaform eruptions with abundant serous exudation are also 
reported. 

1 Vierteljahr., 18S2, ix. 

2 Braunschweig, 1879. 

3 Cf. D. W. Montgomery. Trans. Med. Soc. of State of Cat., 1900, review of 
subject with bibliography; and Eosenthal, Archiv, 1901, lvii., p. 3, review of subject 
with account of histological changes in one case. 



DEEM ATI T1S MEDICAMENTOSA. 



265 



A number of cases are on record in which the administration 
of the drug was followed by the production of bullse. Bumstead, 
Taylor, Duhring, Tilbury Fox, Finny, and I have described such 
bullae in adults as well as in children. 1 Hallopeau 2 also reports 
a fatal case in which a bullous eruption followed the ingestion of 
potassium iodide. The eruption occurred chiefly about the head and 
neck and the upper extremities. The significant rarity of vesicular 

Fig. 52. 




Papilloma, due to the ingestion of the iodine compounds. 

and bullous lesions in acquired syphilis suggests that at least some 
of the cases on record were those of rashes induced by the remedy 
given for the relief of the disease. 

A careful analysis of these bullous rashes leads to their division 
into three categories : first, those occurring, often with fatal results, in 
cachectic adult patients ; second, those occurring as part of the erup- 
tive lesions in a polymorphic group; third, those occurring in well- 

1 J. C. D., 1886, iv., p. 383. 

2 Union med., 1882, xxx., p. 481. 



266 BYPERMMIAS AND INFLAMMATIONS. 

nourished children, and taking on the appearance of molluscum epith- 
eliale and condyloma-lesions, usually compounded of papulo-vesicles 
and pustules. Erythemata of a similar type have also been recog- 
nized after the ingestion of potassium bromide by infants. 

The pustules induced by the administration of iodine compounds 
are seen chiefly upon the face, the neck, the trunk, and the arms. 
They are usually seated upon a firm base, and may be followed by 
cicatrices. Duhring has seen an annular patch upon the forehead, 



Fig. 53 






^s 







Dermatitis medicamentosa. (Howard Fox.) 

made up of minute vesico-pustules, which eventually developed into 
a globular violaceous mass nearly two inches in diameter. Large, 
cherry-sized, tubercular or papillomatous elevations abruptly rising 
from the surface of the integument may present a cribriform structure 
which shows the open ducts of several suppurating follicles (chin, 
cheek, nose). A few cases are reported in which fungating tumors 
were found, producing an appearance almost identical with that of 
mycosis fungoides. Neumann 1 calls attention to the fact that these 
severe forms of iodide-eruption occur in patients suffering from al- 
buminuria. 

The purpuric rash occurs in petechial macules, discrete and mi- 
'Archiv, 1899, xlviii., p. 323. 



DERMATITIS MEDICAMENTOSA. 267 

liary, situated chiefly on the lower extremities. In a case reported 
by Mackenzie (quoted by Van Harlingen) a dose of 2^ grains (0.166) 
taken by an infant was followed by a fatal result after petechise 
appeared. 

Iodoform. — The internal administration, or the absorption through 
wounds, of this drug has been followed by macular, papular, vesicular, 
bullous, petechial, and mixed eruptions. Grave, and even fatal, sys- 
temic results are noted, including fever, delirium, emaciation, and 
nephritis. (For the local effects of the drug see Dermatitis 
Venenata.) 

Jaborandi and Pilocarpine are capable, when ingested, of inducing 
free diaphoresis ; erythematous macules, wheals, and pinhead-sized 
papules have been seen upon the surface as a result. 

Mercury. — Mercury when ingested is reported to have produced an 
erythematous rash upon the surface of the skin. In view of the fact 
that the metal has been, in its various compounds, administered for so 
long a period of time and for so many various diseases, without the 
production of cutaneous symptoms, it is a fair hypothesis that in the 
few reported cases there was coincidence rather than causation. Mer- 
curials when applied to the external surface of the body are, as is well 
known, capable of exciting, in various degrees, cutaneous irritation 
and inflammation. 

Opium and its Alkaloids. — Erythema, wheals, and occasionally in- 
tense pruritus, with oedema, and subsequent desquamation, have fol- 
lowed the ingestion of opium and several of its alkaloids, notably 
morphine. In its mildest expression this cutaneous effect is limited 
to a characteristic itching about the nostrils that can be perceived in 
a large proportion of all patients as soon as the general effect of the 
opiate becomes, apparent. In some patients there may follow an in- 
tense and distressing general pruritus without efflorescence, and it is 
certain that the subsequent urticarial efflorescence is caused by the 
free diaphoresis which the medicament induces. This fact is a mat- 
ter of practical moment, as the use of an anodyne for the purpose 
of procuring sleep for a patient tormented with a nocturnal pruritus 
would seem to be occasionally indicated. Inasmuch as chloral, potas- 
sium bromide, and the opiates are all capable of aggravating such dis- 
tress, great caution is needful in such emergencies. In general, it 
may be said that the employment of these and similar remedies for 
the relief of pruritus should be interpreted as a confession of weakness 
on the part of the physician, who ought to be able to alleviate the dis- 
tress of his patient by a judicious employment of topical remedies. 

Petroleum and its products are responsible for a large list of medic- 
mentous rashes (see Antipyrin, etc.). 

Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of 
a young girl who exhibited a pemphigoid rash after the ingestion of 
phosphoric acid. According to Farquharson, phosphorus itself is oc- 
casionally responsible for purpura with gastro-intestinal derangement 
and jaundice preceding a fatal issue. 



268 HYPEREMIAS AND INFLAMMATIONS. 

Podophyllum — Winterburn 1 reports that those who work in resinoid 
podophyllin are liable to suffer, as a consequence of this exposure, 
from a cutaneous disease of the scrotum. 

Potassium Chlorate. — Stelwagon and others report that papules 
and macules have followed the use of this remedy, administered in the 
form of tablets. 

Quinine, Cinchona, and Cinchona Alkaloids. — Morrow 2 collected the 
records of over sixty cases of quinine-exanthem, and he shows that 
its prevailing type is exanthematous, the rash being of a vivid hue, 
disappearing on pressure, and resembling scarlatina. Other lesions 
produced are wheals, papules, vesicles, petechia?, hemorrhagic pur- 
pura, bullae, and in one instance an intense localized dermatitis with 
beginning gangrene of the scrotum. In some of the cases the rash 
appears on repetition of the dose, and even after recourse to other 
alkaloids. The subjects are mostly women. As with most of the 
other exanthem-producing drugs, small doses suffice for the effect 
where the idiosyncrasy exists. The rash has been studied in an 
adult male, who, after taking 2 grains (0.133) of quinine sulphate 
for the first time in six years, exhibited an efflorescence (over the 
entire surface of the body) of discrete finger-nail-sized, salmon- 
and pinkish-tinted, scarcely elevated patches, accompanied by mod- 
erate pruritus. A repetition of the dose was followed by a recurrence 
of the exanthem. 

In several cases desquamation is reported as resulting from the 
rash. As to the occurrence of the general symptoms recognized under 
the title "cinchonism" (tinnitus aurium, etc.), these may and may 
not accompany the lesions. Morrow makes the pertinent suggestion, 
in view of the frequent similarity of the rash to thai c.\liiliitc<] in scar- 
latina, that many cases hitherto recorded as recurrent attacks of that 
disease and measles, with other anomalous cutaneous eruptions, may 
have been instances of quinine-exanthem. 

Salicylic Acid and the Salicylates. — Reports of cases in which these 
substances after ingestion produced cutaneous symptoms have been 
made by Heinlein, Wheeler, and Freudenberg, all cited by Van 
Harlingen. The symptoms were diffused redness, urticarial lesions, 
vesicles, pustules, petechia?, and vibices, accompanied by intense 
pruritus and followed by desquamation. Engman 3 reports an in- 
teresting case, including the histology of the lesions. 

Salipyrin,— (Edema of the skin and actual loss of tissue have re- 
sulted from the administration of gramme doses of salipyrin to a man 
aged fifty-four years (Schmey). 

Santonin. — A generalized eruption of urticarial lesions seated 
upon a reddened surface and accompanied by cedema is reported by 
Sieveking as occurring in a child to whom santonin had been adminis- 
tered as a vermifuge. 4 

1 Louisville Med. News, 1882, xiii., p. 187. 
»N. Y. Med. Jour., 1880, xxxi., p. 244. 

3 J. C. D., 1899, xvii., p. 555. 

4 Brit. Med. Jour., February 18, 1871. 



DEEMATITIS MEDICAMENTOSA. 269 

Serum Eruptions. 1 — Tuberculin, diphtheria-antitoxin, and the va- 
rious vaccines used as therapeutic measures frequently produce in 
susceptible individuals cutaneous exanthems. As the antitoxin of 
diphtheria is used so commonly to-day, the exanthems produced by 
its employment should be recognized. 

Frequency. — Owing to the fact that different serums produce 
eruptions in varying proportions, and also to the fact that accurate 
records are kept chiefly in hospitals where the injections are used as 
a routine measure, and also by a few men specially interested in the 
matter, the exact proportion of persons displaying eruptions in rela- 
tion to the whole number treated is difficult to determine. Hartung 
collected data from the literature on the subject and from the reports 
of twelve observers found 294 eruptions resulting from 2661 injec- 
tions, an average of 11.4 per cent. 

Date. — The appearance of these eruptions may occur from one 
to thirty days after the injection. The majority appear from the 
sixth to the tenth day. 

Character. — The important exanthems in the order of frequency 
of occurrence are the following : Urticarial, polymorphous, erythema- 
tous, scarlatiniform, morbilliform, vesicular and bullous, and pur- 
puric. The last three are rare. The majority are urticarial, and 
may be ordinary urticarial wheals or urticarial erythema. The 
scarlatiniform and morbilliform varieties closely resemble the dis- 
eases after which they are named. Mixed types are common and 
aid in diagnosis. (Edema, especially of the face, about the eyelids, 
also of the penis, scrotum, and feet is not infrequently noted in as- 
sociation with these eruptions. The distribution of the lesions is 
irregular. While they may occur on any part of the cutaneous 
surface, the sites of predilection are about the arms, legs, buttocks, 
and trunk. The face occasionally may be attacked. The first ap- 
pearance of the eruption is commonly about the site of injection. It 
is frequently noted that the eruption appears within twenty-four 
hours at the site of the injection and soon clears but reappears later 
generalized. The extent of the eruption varies from a few isolated 
scattered patches to a profuse exanthem, involving almost the entire 
cutaneous surface. Its duration is commonly about two, but it may 
persist for three, four, or five days. Purpuric lesions naturally 
persist for a longer period. The eruption may recur within a few 
days after disappearance, or after some weeks. The dates of recur- 
rence vary from three to seventeen days. More than one recurrence 
may happen. 

These rashes are commonly accompanied by constitutional dis- 
turbance of varying degree. There is usually a rise in temperature 
with its accompanying symptoms. While this rise usually does not 
exceed 101° to 102°, it may be as high as 105°. The fever lasts 
from one to three days, subsiding with the disappearance of the erup- 
tion. Headache, a certain amount of prostration, and arthralgia 

4 Welcb and Scbamberg,, Treatise, Acute Contagious Diseases, pp. 754-760, 



270 HYPEREMIAS AND INFLAMMATIONS. 

are common accompaniments. The joint pains are valuable aids in 
diagnosis. 

It is believed that these cutaneous manifestations are induced 
by the serum per se, and that the antitoxic material has little to do 
with their production. Similar eruptions have been produced re- 
peatedly by non-immunized serum. 

Sodium Benzoate. — Rohe 1 reports two cases in which an erythema- 
tous rash, with well-defined border, accompanied by itching and 
slight desquamation, occurred during the use of sodium benzoate. 
The patients were a woman, aged thirty-five years, and a boy suffer- 
ing from diphtheria. The eruption disappeared on discontinuance of 
the remedy, and was made successively to appear and disappear by its 
alternate use and disuse. 

Sodium Biborate. — Gowers 2 reports the occurrence, especially on 
the arms, but also over the trunk and legs, of an eruption resembling 
psoriasis, after the ingestion of sodium biborate. Some of the re- 
sulting patches were one and a half inches in diameter. Three cases 
in all are collated. In two the eruption faded when a solution of 
arsenic was added to the sodium salt. 

Stramonium. — "Deschamps (cited by Duhring) reports an erythem- 
atous rash after the administration of the thorn-apple. 

Strychnine. — Skinner (cited by Van Harlingen) reports a case in 
which an eruption of six weeks' duration ensued upon the administra- 
tion of quinine and strychnine together; the former in the dose of 
1£ grain (0.10) the latter in the dose of & grain (0.0025). 

Sulphonal. — Diffuse macular and scarlatiniform eruptions are seen 
occasionally. Vesicular and purpuric lesions have also been reported. 

Tanacetum. — A case of varioliform eruption produced by the in- 
gestion of H drachms (6.) of the oil of tansy, administered for abor- 
tifacient purposes, is reported by Potter. 3 There were antecedent 
clonic convulsions. The result was not fatal. 

Tar and Turpentine. — Erythematous, vesicular, and papular rashes 
are reported as resulting from the ingestion of these substances. 

Veronal. — Wills, 4 House, 5 Bulkley, 6 Wooley 7 and others have re- 
ported instances of eruptions produced by this drug. Their occur- 
rence is due to idosyncrasy and the lesions belong to the group of the 
angioneurotic dermatoses. They may be exhibited as local or general 
exanthems. Erythema, large maculo-papules, vesicles, oval and cir- 
cular patches with dark centers resembling insect bites, scarlatiniform 
erythema, and oedema, especially of the face, have been described. 
On clearing, brownish stains and petechial spots remained for a time. 
Constitutional symptoms of moderate grade accompanied the general 
eruption. 

1 Maryland Med. Jour., 1881, viii., p. 91. 

2 Lancet, 1881, ii., p. 546. 

3 New England Med. Jour., October 15, 1881. 
*W. K. Wills, Brit. Med. Jour., 1906, March 3. 
5 Wm. House, J. A. M. A., 1907, xlviii.. p. 1349. 
6 L. Duncan Bulkley, ibid., 1907. xlviii., p. 1865. 
7 Paul G. Wooley, ibid., 1907, xlix., p. 2153, 



DERMATITIS MEDICAMENTOSA. 271 

The following medicaments may be added to the list of drugs 
capable of producing rashes when administered by the mouth : 

Anacardium, alcohol, bitter almonds, antimony, argenti nitras, benzol, 
chinolin, bitter-sweet, capsicum, duboisin, ferrous iodide, guarana, kava- 
kava, creosote, resin, castor-oil, ipecacuanha, hyoscyamus, lactophenin, 
matico, lead and its compounds, mesotan, sulphur and calcium sulphide, 
veratrum viride, cocaine, conium, pimpinella, rhubarb, and valerian. 

Many of these drugs have been effective in but few instances. 
There is no reason why the list should not in the future greatly be 
enlarged, as it is probable that every medicament is capable of pro- 
ducing a temporary efflorescence when the system exhibits a special 
sensitiveness to its action, the character of the eruption depending 
largely on individual idiosyncrasies, and on the circumstances (includ- 
ing the condition of the tissues) attending the administration of the 
drug. 

Etiology. — In Morrow's treatise it is shown that the same drug 
may produce a variety of eruptive phenomena, and that the same 
eruptive features may result from the ingestion of different drugs. 
He points to what he concludes to be the neurotic origin of many 
of these rashes, and believes that the proof is inconclusive that they 
are to any considerable degree brought about by elimination, through 
the cutaneous glands, of the noxious element introduced with the 
drug. Tilden, however, calls attention to the fact that many of 
these eruptive phenomena are of the nature of angioneuroses, similar 
to Trousseau's tache cerebrale, requiring often increase in the irrita- 
bility of the cutaneous vessels, with exudation of serum, outwandering 
of blood-cells, and, in case of hemorrhagic lesions, some change in the 
vascular walls themselves. 

Diagnosis. — The diagnosis of the various medicinal rashes de- 
scribed above does not, fortunately, demand a recognition of the essen- 
tial peculiarities impressed upon each by the exciting cause, since in 
many cases such peculiarities do not exist. The same drug may, on 
the one hand, produce a rash with symptoms widely differing in a 
group of patients, while, on the other hand, the urticarise resulting 
from the ingestion of "head-cheese," quinine, and chloral may be 
indistinguishable. But to establish the fact that a medicamentous 
eruption is present in any given case is a long step in the direction 
of reaching the precise cause that has been in that case effective. 
This information must often be obtained from the lips of the patient. 
The medicinal rashes are in general remarkable for their sudden ap- 
pearance, their symmetry, their diffusion over large areas of integu- 
ment, the presence of pruritus, the absence of fever, and their exist- 
ence alike upon exposed and protected surfaces of the skin, thus 
hinting at the action of some cause not operating externally. Exclud- 
ing syphilis and the exanthematous fevers, a generalized rash of 
sudden occurrence should always raise the suspicion of a dermatitis 
medicamentosa. Similarly in cases of preexisting cutaneous disease, 
syphilis, eczema, or psoriasis, the sudden occurrence of lesions of a 



272 HYPEREMIAS AND INFLAMMATIONS. 

new type widely diffused, or of rapid aggravation in situ, or of speedy 
extension in the area of those already in existence, should awaken the 
suspicion, if there be fever, of the exanthemata, and, without a febrile 
process, of the medicinal rashes. Thus, have seen two patients 
with eczema exhibit rapid rise in body-temperature, and subsequently 
develop a generalized variolous rash; and it is a matter of common 
experience to examine patients on the eve of a macular syphiloderm, 
or even long past the eruptive stage of that disease, showing their 
faces, necks, and shoulders covered with an acneiform rash produced 
by potassium iodide. The practitioner cannot too strongly be urged 
to view with exceeding watchfulness the skin of a patient affected with 
any of the common disorders (eczema, acne, and psoriasis) when the 
eruption becomes anomalous as to type, distribution, or symptoms. 

Treatment. — The medicamentous rashes, as a rule, disappear 
rapidly after the withdrawal of the exciting cause, and they require 
no further management. In some cases the soothing lotions, baths, 
and dusting-powders employed in the treatment of acute eczema may 
be required. 

It should not be forgotten that the patient who exhibits these 
lesions is usually one who has boon suffering from the real or fancied 
disease for relief of which the drug was taken, and that condition may 
require recognition and management. 

FEIGNED ERUPTIONS. 

(Dermatitis Factitia, Feigned Eruptions, Hysterical Debt 

mato-Neuroses, Hysterical Gangrene, Neurotic Gangrene, 
Spontaneous Gangrene, Erythema Gangrenosum.) 
Feigned eruptions occur in all degrees of dermatitis from a 
simple erythema of a few days' duration to the various vesicular, 
bullous, gangrenous, and ulcerating lesions. The mild and super- 
ficial forms are the more common but superficial gangrene and 
ulcers are not infrequently seen. The degree and severity of the 
process depend not only upon the agent employed but also upon 
the strength of the solution, the duration of the application, and 
the susceptibility of the tissues to which the agent is applied. Thus 
a moderately weak solution of carbolic acid, if applied for a few 
minutes only, will produce in most individuals, an erythema or super- 
ficial dermatitis of a few days' duration. If the solution be stronger, 
or if a weaker solution be allowed to remain in contact with the 
skin longer, severer forms of inflammation and even gangrene may 
result. 

The methods employed in the production of these lesions are 
varied and often difficult to detect. Many different animal, vege- 
table, and mineral substances have been used for the purpose. Among 
those most commonly employed may be mentioned carbolic acid, croton 
oil, Spanish fly, mustard, various acids and caustics, lye, and creso- 
line ; burning with hot water bottles, matches, hot metal ; and friction 
with the finger, pieces of wood, or other rough material. 



PLATE IV 



-_l 






% ^H 


'.'•■' ' '' 


I 




m . Mat 




3 <^&0 



Dermatitis Factitia. 



FEIGNED ERUPTIONS. 273 

Occasionally a skilled malingerer succeeds in imitating more or 
less closely certain definite cutaneous disorders. Among those so 
imitated may be named sycosis, favus, alopecia, ringworm, scabies, 
bromidrosis, hsemidrosis, chromidrosis, erysipelas, abscesses, and 
syphilis. Patients with an eczema or other cutaneous disorder may 
aggravate or prolong the same and make the interference very diffi- 
cult of detection even while under treatment. 

Diagnosis. — The diagnosis of feigned eruptions is usually not diffi- 
cult for one familiar with cutaneous diseases, as the lesions do not 
correspond with those of any recognized disorder. As a rule the 
lesions all occur within easy reach of the patient's hands, and are 
most numerous on the anterior surfaces of the body, on the left arm, 
fore-arm, and hand ; the lower extremities, and right side of the face 
and neck; that is, all regions easily reached by the right hand. In 
case of a left handed individual, the regions most accessible to that 
hand would, of course, show the largest number of lesions. The 
palms, soles, eye-lids, mouth, nose, ears, scalp, and genitals are usu- 
ally spared. 

The lesions are always sharply outlined and of unusual, often 
fantastic shapes. They appear suddenly, at irregular intervals, usu- 
ally one or two at a time, and run a fairly rapid course. When 
fluid caustic is used it frequently happens that one or more drops 
run down the skin from one of the lesions, leaving a characteristic 
streak which is usually lighter in color and shows a less degree of 
inflammation than the patch from which it depends. When the 
caustic is applied with a needle or pin, as is frequently the case in 
gangrenous areas, the border shows an irregular, finely jagged, or ser- 
rated (saw-tooth) edge, made by the numerous punctures in the 
advancing border. When gangrene is present, it is usually very 
superficial, and separated from the normal skin by a narrow, vivid 
red line. The fingers, nails, or some article of the clothing are often 
stained by the agent employed. 

Subjective sensations, usually pain and burning, may be greatly 
exaggerated by the patient, who will then cringe or jump at the 
slightest touch during the examination and will complain bitterly 
of the distress caused by the simplest and lightest of dressings. On 
the other hand, the areas may be largely anaesthetic and some of these 
individuals like to exhibit their ability to endure pain. Many of the 
patients enjoy mystifying their medical attendant by predicting from 
twelve to twenty-four hours in advance the exact areas upon which 
new lesions will occur, claiming that during this period they exper- 
ience in these areas a sense of heat and burning and other queer sen- 
sations. 

Further aids to diagnosis may be found in the general character- 
istics of the patients. The unusual history of the disorder, the dis- 
covery of anaesthetic areas especially of the fauces and conjunctiva, 
and other evidences of hysteria. Finally, if necessary, a fixed dress- 
ing that cannot be removed without detection may be used to clear the 
diagnosis. 



274 HYPEREMIAS AND INFLAMMATIONS. 

The patients presenting feigned eruptions may be roughly divided 
into two classes : First, deliberate malingerers, such as criminals, sol- 
diers, sailors, and others desiring to escape punishment or service ; ser- 
vants, nurses, and others desiring to avoid disagreeable duties or sur- 
roundings; and paupers or mendicants seeking charity, hospital ac- 
commodations, or other assistance. Second, hysterical and neurotic 
individuals, chiefly women and girls, who inflict these injuries upon 
themselves for reasons not always definitely recognized. With this 
class of patients there is frequently a desire, more or less definitely 
recognized by the patient, to escape from disagreeable duties or sur- 
roundings, to gain attention, sympathy, interest, or pity, or to achieve 
notoriety. The sexual element is not infrequently present. Awak- 
ening sexual desire, possibly not definitely recognized, in the develop- 
ing girl ; excessive or abnormal sexual activity ; orgasm induced by 
torturing the skin; and a certain satisfaction experienced through 
exposing the body for examination, are features recognized in some 
of these cases. In some instances, the patient, while not recognizing 
any motive, states that she is subject at times to sudden irresistible 
impulses to produce these lesions. Such impulses may be the result 
of "suggestion" or of the "fixed idea." In a large proportion of 
cases the factitious eruption is preceded by some light wound or abra- 
sion of the skin to which an antiseptic dressing has been applied. 
The patient is thus provided not only with a source for the suggestion 
but also with the means for carrying it out. The extent to which 
hysterical young women will injure themselves is illustrated in two 
of the author's patients both of whom submitted to amputation of the 
fingers, and one demanded amputation of the entire hand, for gan- 
grene produced by themselves with carbolic acid. 

Treatment. — The chief object to be attained for relief of these pa- 
tients is to induce them to acknowledge the facts. "New lesions then 
cease to appear, and the management of existing lesions should be in 
accordance with the rules laid down in the chapter on dermatitis. 

X-RAY DERMATITIS. 

The symptomatology, etiology, and pathology of x-ray dermatitis 
are considered under Radiotherapy. 

Treatment. — A better understanding of the possibilities of the 
x-rays has developed a technique, the careful following of which 
should prevent severe x-ray burns, except in rare instances where it 
is thought advisable to risk the danger of such a burn for the sake of 
quickly destroying a rapidly progressing malignant growth. Even 
the mild forms of x-ray dermatitis can usually be avoided by the 
exercise of proper skill and care. 

The simpler forms of dermatitis due to x-rays may often be 
treated successfully with the measures recommended for correspond- 
ing phases of eczema and dermatitis due to other external causes. 
Frequently, however, even a mild dermatitis due to x-rays is persis- 



EADIO-DEBMATITIS. 



275 



tent and exceedingly painful, and not infrequently is aggravated 
rather than relieved by measures applicable to corresponding grades 
of dermatitis from other causes. In such cases various applications 
with or without some local anodyne may be tried. Among those we 
have found the most useful are the following: The lead and opium 
wash with or without the addition of a powder, glycerin, or boric 
acid, as recommended for the treatment of acute eczema ; a mixture 
of equal parts of this lotion and carron oil (made with olive oil) ; 

Fig. 54. 




Radio-dermatitis, third degree, upon keratodermia. 



compound stearate of zinc powder; a simple ointment containing 
one or two drachms of orthoform to the ounce. We have found the 
following paste, recommended by Engman, 1 very satisfactory: 

"Boric acid, 12 drachms (48.) ; zinc oxide, starch, bismuth sub- 
nitrate, and oleum olivfe, of each 1 ounce (30.) ; liquor calcis and 
lanoline, of each 3 ounces (90.) ; rose water, 12 drachms (48.). The 
powder should be well rubbed up in a mortar, the lanoline added; 
the olive oil and liquor calcis then are mixed and slowly added ; when 
this is mixed thoroughly the rose water is added, and the whole beaten 
up in the mortar into a light, creamy paste." 

The surface should be kept covered with this paste, spread on old 
linen or several thicknesses of gauze. A sheet of gutta-percha tissue 
may be placed over the dressing to prevent evaporation, unless this 
is uncomfortable, as it sometimes is, to the patient. 

In deep-seated ulcers, which fortunately are seen but rarely, the 
treatment is usually surgical, the necrosed tissue having to be re- 
moved and the surface covered with skin-grafts. 
1 B. J. D., 1903, xv., p. 390. 



276 HYPEREMIAS AND INFLAMMATIONS. 

PSORIASIS.* 

(Gr., ¥upa, the itch.) 

(Lepra, Alphos, Psora. Ger., Schuppenflechte.) 

Psoriasis is a chronic, occasionally acute, inflammatory disease, 
characterized by reddish-brown flat papules or sharply circumscribed 
plaques or areas of varying size covered with silvery-white imbricated 
scales. 

In surveying the enormous mass of literature accumulated on the 
subject of psoriasis, it is of the utmost importance, from the point 
of view of clarity, that the pure types of the disease should be dis- 
associated from others; and especially that the large list of complica- 
tions and anomalies of dermatoses described as " psoriasis " should 
not be confounded with the classical and well recognized picture of 
the affection. Between three and six per cent, of all diseases of the 
skin are represented under the title psoriasis. It is clear, therefore, 
that the disease must occur among all sorts and conditions of men 
and women, that it often develops in persons suffering from other 
diseases and even from other dermatoses; and that the accidental 
features of any one ease should not be regarded as characteristics of 
the essential malady. 

Symptoms. — In typical evolution the papules and plaques of 
psoriasis always are defined sharply from the surrounding skin, some- 
what infiltrated, slightly elevated, and covered more or less com- 
pletely with silvery-white or mother-of-pearl colored scales which are 
arranged in thin layers like mica. On removal of the scales there is 
exposed in recent lesions a bright-red surface; in older lesions the 
color is of a duller hue. If the deepesl scale, which often is thin, 
translucent, and closely adherent, is pulled or scraped off, there can 
be seen several minute bleeding points which correspond to the apices 
of papilla' beneath. The lesions vary greatly in number, size, shape, 
and distribution, but the type, that of the dry papule or plaque cov- 
ered with scales, remains always the same, so that in uncomplicated 
cases psoriasis is distinctly a dry disease without vesicles, pustules, 
or other moist lesions. 

The primary lesion of psoriasis is a pin-point- or pin-head-sized 
flat, round or oval, sharply defined, slightly elevated red papule, 
which always at the earliest moment of observation is covered either 
entirely, or all but a narrow rim at the border, with delicate silvery- 
white or mica-like scales. The bleeding points produced by forcibly 
removing the scales may be so minute that they are only visible with 
the aid of a lens. As the lesion grows peripherally, it may become 
somewhat more infiltrated, slightly more elevated, and covered with 
more abundant imbricated scales, but otherwise it retains its original 
characteristics. Larger plaques and areas all are formed either by 
the gradual increase in size of the original papules, or by the coales- 
1 For complete bibliography, see Grosz, Mracek's Handbuch, Bd. ii., pp. 126-168. 



PSORIASIS. 



277 



cence of a number of papules or smaller plaques. The papules and 
small plaques formed by the peripheral growth of single papules are 
usually round or oval, but areas formed by the coalescence of smaller 
plaques are irregular in outline. In the borders of such patches 
traces of the original lesions can usually be detected. As a matter of 
convenience, descriptive terms have been applied to the lesions of pso- 
riasis to denote their size and arrangement. 

When the disease appears in the form of small scale-covered 
points, it is called psoriasis punctata. Should the disease progress 
to fuller development, patches of larger size form, always with a 




Psoriasis, generalized and in large plaques. 

definite contour, very slightly elevated above the general level of the 
integument, and covered with whitish, mother-of-pearl colored scales 
in abundance. When the lesions approximate the size of drops of 
water, the disease is termed psoriasis guttata. In more advanced 
conditions of the disease other names are employed. Thus psoriasis 
nummularis or discoidea is characterized by small-coin-sized patches ; 
psoriasis circinata or orbicularis, by patches in which the disease is 
exhibited actively at the periphery of a circle, the centre of which is 
free from disease, a condition due usually to the involution of the 
centre of an area as it extends peripherally; psoriasis gyrata and 
figurata, by coalescence and extension of several patches, forming 
thus fantastic figures ; and psoriasis diffusa, by much more extended 
and uniform involvement of the skin in large areas. In psoriasis 
follicularis the coil-glands and hair-follicles are invaded chiefly. 

Areas of long persistence in which the skin is infiltrated deeply, 
often fissured, and covered with heavy scales, are designated fre- 
quently as psoriasis inveterata. In a given case the lesions may be of 



278 



HYPEREMIAS AND INFLAMMATIONS. 



Fig. 56. 



fairly uniform size, but more commonly, if at all numerous, they 
exhibit different stages of development and therefore vary in size. 
They may be arrested at any stage of growth and persist for months 
or years as guttate, nummular, or larger plaques, or by continued ex- 
tension and coalescence form areas covering an entire region of the 
body. Though cases are reported in which the surface of the entire 
body iscovered, it is rare that areas of normal skin cannot be detected. 
In number and distribution of its lesions, and in its course, psori- 
asis varies greatly. The disease commonly begins with one or two 

small papules which increase slowly 
in size. In ordinary cases new lesions 
appear during the course of weeks, 
months, or years, until there are from 
ten to one hundred or more patches 
of varying size scattered over the body. 
It is not unusual, however, for the 
disease to remain for years limited to 
two or three coin-sized areas, situated 
commonly over the elbows and knees. 
Occasionally a single patch may per- 
sist indefinitely without the appear- 
ance of others. In other instances, 
but chiefly in recurrences of the dis- 
ease, a large number of punctate pap- 
ules may appear within a iew days. 
In the same individual, tire number, 
size, and distribution of the patches 
vary from time to time. With many 
patients the psoriatic areas partially 
or wholly disappear in summer, only 
to return in cold weather. In a 
smaller number of cases the disease 
is worse in summer, and better, or 
entirely absent in winter. Without 
the influence of climate or of any 
other known cause, the disease may 
disappear partially or wholly for 
months or years and then return. In 
recurrences of the disease the lesions 
do not necessarily correspond in num- 
ber, size, or distribution with those 
of earlier attacks. In acute febrile 
and other intercurrent diseases 
patches of psoriasis may fade or dis- 
appear temporarily. 
Involution of a patch of psoriasis begins in the centre, and is 
recognized by a diminution in the hyperemia and of the scaling. 
The process progresses slowly until no trace of the disorder is left. 




Psoriasis (large plaques). 



PSORIASIS. 279 

Temporary pigmentation may remain for weeks, on the lower ex- 
tremities for months, after the scaling and infiltration have disap- 
peared completely. Should the areas spread peripherally while heal- 
ing in the centre, circular and oval bands are formed. By the union 
of a number of such bands are produced circinate and gyrate figures 
or festoons which may occupy the entire surface of the back or other 
region of the body. 

In distribution, psoriasis is, as a rule, symmetrical, but exceptions 
to the rule occur. The sites of preference of the disease are the ex- 
tensor surfaces of the extremities, especially about the elbow and the 
knee, in which situation it is decidedly most common. After these 
locations should be named, in order, the scalp, the region of the sa- 
crum (on which often the largest patch upon the body can be discov- 
ered), the upper surface of the chest, the face, the belly, and the 
genitals, more rarely the hands and the feet. 

Upon the scalp, plaques of well-defined contour, covered with 
thick whitish scales, may mat the hairs, but alopecia rarely results. 
The dry condition of these scales contrasts with the greasiness of the 
crusts formed in seborrhoea of the scalp. Often a fillet or band of 
diseased tissue, one or more inches in width, projects beyond the 
border-line of the scalp and forehead. When the vertex is bald from 
physiological loss of hair the patch of psoriasis usually lingers near 
the fringe of the hairs left at the sides of the head, projecting thence 
to the regions of baldness. On the face, as well as over the genitals, 
the lesions are usually both indistinct and small-sized, being dis- 
played, as regards the former locality, over the cheeks, chin, and 
nose, avoiding the parts near the mucous orifices. On the scrotum 
psoriasis frequently is complicated by fissures, moisture, and other 
evidences of acute inflammation. 

The hands, feet, fingers, and toes are not often involved, and the 
palms and soles only so rarely invaded as to throw doubt upon a diag- 
nosis based upon the existence of the disease solely in these regions. 
We have had two cases in which the disease was limited to the palm 
for considerable periods of time, but later appeared in characteristic 
forms on other parts of the body. Other writers report similar in- 
stances. In severe cases the nails are attacked secondarily, being 
thickened, eroded in points, irregularly laminated, rigid, and becom- 
ing brittle and yellowish-white or dirty-whitish in color. In some 
cases, however, the nails are primarily if not exclusively attacked. 
(Of. the chapter on Diseases of the Nails.) On the palms and soles 
the lesions may show, instead of scaling, sharply circumscribed areas 
in which the horny layer is much thickened. Occasionally bullous 
lesions develop in these regions. 1 Through cracking and partial de- 
struction of horny masses the patches may assume a worm-eaten 
appearance. 

Psoriasis is not known to affect the mucous surfaces. The lesions 
of so-called "psoriasis linguae" are those of "leukoplakia buccalis," 

1 Psoriasis -palmaire avee soulevements d 'apparence bulleuse, MM. Hallopeau et 
P. Salmon. Bulletin de La Societe Fran., 1908, p. 243. 



280 EYPEEMMIAS AND INFLAMMATIONS. 

or " smokers' patches," of syphilitic disease of the mouth, or flat epi- 
theliomata. 1 Schiitz 2 reports two cases and refers to others, in which 
psoriasis was associated with mucous membrane lesions. These 
lesions, however, occur with other cutaneous and systemic disorders, 
and their relation to psoriasis is not demonstrable. 

In a patient subject to psoriasis a local irritation, such as a pin- 
scratch, a mustard plaster, may cause new lesions to appear at the 
site of irritation. Crocker 3 describes a form of psoriasis punctata 
in which the lesions, though numerous, are limited to the sweat- 
ducts, and another form of punctate psoriasis in which the papules 
are situated about the hair-follicles. 

The amount of scaling varies greatly in different persons and in 
the same individual; ordinarily the scales are abundant and thickly 
heaped up over even small areas ; sometimes they are sparse over 
large areas. Free perspiration, friction by the clothing, or frequent 
bathing may prevent the accumulation of scales on areas where they 
would otherwise be abundant. Where the epidermis is thin the scal- 
ing is less ; therefore, over flexor surfaces, near the mucous orifices, 
and on the back of the hands, the scaling is less than over extensor 
surfaces, in regions remote from the mucous orifices, and on the palms 
and soles. The scaling is also less in youth than in advanced years. 
The scales may adhere with considerable firmness to the patch, or 
may be shed freely from the surface, in pronounced cases powdering 
the clothing of the patient or the sheets of the bed upon which he 
reposes at night. 

Instead of a lustrous white, the seales may display a deep-yellow- 
ish shade, and, instead of being imbricated, may form a thin con- 
tinuous sheet of exfoliated epidermis. When the eruption is disap- 
pearing the scales fall, leaving a pigmented or slightly discolored 
patch of integument. 

Psoriasis is essentially a chronic disease, but may present at times 
acute exacerbation, and occasionally begins as an acute process. In 
the acute stages the inflammatory symptoms are more marked; the 
lesions are of a brighter red color and not so sharply defined a3 in 
the ordinary forms of the disease; the scales are also few in number, 
thin and easily detached, and the sensations of burning and itehing 
may be severe. When acute, the papules are usually numerous and 
punctate, and may appear on the face ; in other instances the patches 
may be as large as a small saucer; are dark or lurid red over the 
whole ; are covered with a more uniformly constituted, thin, squamous 
film or sheet of semitransparent delicate membrane through which the 
red glare of the patch beneath is visible. This condition may be 
seen also in young persons to whom arsenic has been administered 
for the relief of the disease, with the production of irritative effects. 

J An emphatic corroboration of this dictum is given in the discussion of a 
case reported by Seo (Annales, 1903, iv., 219) ; see also Oppenheim, Annales, 
1905, s. iv., vi., 379. 

1 Archiv, 1899, xlvi., p. 433. 

3 Diseases of the Skin, 3d ed., p. 361, and Atlas, plates 25 and 26. 



3 fl 

O o 




03 3 
tf 

o 5 

Is 

■a % 


0, 

73 
N 

"5 

S-, 

c 





PSOBIASIS. 281 

An acute attack may come and go as such, but usually it terminates 
in a chronic form of the disease. 

Subjective sensations may be entirely absent in psoriasis, even 
when it is extensive. There is, however, usually slight and occasion- 
ally severe itching. In acute cases burning and smarting are often 
present. In exceptional cases the subjective sensations interfere with 
sleep and rest ; otherwise the disease does not affect the general health 
of the patient. 

Atypical and complicated forms of psoriasis 1 occur in which the 
character of the lesions is modified considerably. Earely the scales 
may be heaped up in the centre in the form of an oyster-shell, pro- 
ducing what is termed psoriasis rupioides or psoriasis ostreacea. In 
a few instances the accumulated scales have assumed the appearance 
of a cutaneous horn. 2 Hypertrophy of papillae may produce wart-like 
lesions, designated as psoriasis verrucosa (Besnier, Kaposi, Crocker). 
The scales may be slightly greasy and the surface beneath exhibit a 
trace of moisture, making the diagnosis between psoriasis and derma- 
titis seborrhoica difficult if not impossible ; indeed the two conditions 
may be associated. Occasionally, in moist situations, on the sensitive 
skins of children, or as an effect of local irritation or infection, the 
patches may be inflamed acutely and indistinguishable from ordinary 
eczema. 

There can be no question that intermediate forms between eczema 
and psoriasis occur, in which forms it is difficult to determine whether 
the two disorders coexist or the one has assumed the features of the 
other. In these cases there may be itching and infiltration of the 
skin, with vesicular and other lesions foreign to psoriasis, and a catar- 
rhal discharge. 3 

Cavafy, 4 Kusnitsky, 5 and others report cases in which psoriatic 
lesions, though numerous, were limited to one side of the body. We 
have had such a case in which the psoriatic lesions were limited to the 
site of a linear nsevus. Tscherbakore 6 reports a case of universal 
psoriasis occurring in a neurotic subject. 

The sequelae of psoriasis are, as a rule, nothing more than a 
transitory pigmentation, but cases are reported in which involution 
of the lesions has been followed by superficial scars (Crocker, 
Hutchinson), keloid formations (Anderson, Purdon, Crocker), per- 
sistent deep pigmentation (Crocker), or permanent achromia (Hallo- 
peau, 7 Bille 8 ). In some cases these unusual sequela? were due un- 
doubtedly to treatment. A few instance have been reported by J. C. 

1 Beyer reviews the subject and attempts a classification of reported cases. 
Wien. klin. Wchnschrft., 1901, xiv., p. 805. 

2 Gossman, Arch., 1897, xli., p. 357. 

3 The causes of moist forms of psoriasis are considered by Benassi, Giorn. ital., 
1901, xxxvi., p. 427 (abstr. in Monatshefte, 1901, xxxiii., p. 460). 

4 Cited by Crocker. 

5 Archiv, 1897, xxxviii., p. 405. 

6 Monatshefte, xliv., p. 438. 

7 Annales, 1898, s. iii., ix., p. 690. 

8 Ibid., 1901, s. iv., ii., p. 80 (report of ten cases; discussion). 



282 BTPEB&MIAS AND INFLAMMATIONS. 

White, 1 Hartzell, 2 and others, in which epithelioma has followed verru- 
cous lesions which developed upon psoriatic patches. Some, possibly 
all, of such changes were due, as suggested by Hartzell, to previous 
long-continued use of arsenic for the psoriasis. When extensive, and 
especially after persisting for a number of years without amelioration, 
psoriasis may lose its distinguishing features and assume all the char- 
acteristics, both clinical and pathological, of dermatitis exfoliativa. 

Etiology. — The causes of psoriasis are not known. Sex, social 
condition, and occupation evidently play little or no part in the 
etiology. The disease is common, comprising nearly 4 per cent, of 
all cutaneous affections reported in America. The disorder occurs 
most frequently in the second and third decades of life, but no age 
is exempt. It is unusual for the first attack to appear after forty-five, 
and the disease is uncommon under ten and rare under three years of 
age. Rille 3 reported a case in which the disease appeared in an 
infant six days old. Other cases in infants less than one year old 
have been reported by Neumann, Kaposi, and others. Benassi 4 re- 
ports fourteen cases between the ages of sixteen months and ten years. 
Heredity is seemingly a factor in a considerable number of cases, 
in so far as inherited predisposition or susceptibility to psoriasis is 
concerned ; but direct transmission of the disease itself by inheritance 
has not been demonstrated. A family history of psoriasis is the ex- 
ception rather than the rule. Several careful observers, however, have 
believed that the disease often is hereditary. It is of great rarity 
ill the dark skinned races. Hubbard and others 5 report a few cases 
in negroes. 

The disease apparently bears no definite relation to any one sys- 
temic condition. It appears in individuals who are apparently in 
perfect health as well as in the delicate and in those ill of other dis- 
orders. Defective assimilation and elimination, such as exist in gout, 
rheumatism, and other arthritic disorders, as well as in plethoric 
and overfed individuals, certainly exercise an unfavorable influence 
on psoriasis. Nagelschmidt 6 has striven to indicate a relation be- 
tween psoriasis and pancreatic disease. Psoriasis occurring in cases 
of arthropathy is reported by Mentzer and Adrian. 7 Associated 
with such conditions psoriasis is usually indolent in type but exceed- 
ingly persistent, unless the systemic condition be improved. In the 
neurotic and poorly nourished, psoriasis is also persistent, but usu- 
ally with more acute symptoms. The disease has been attributed 

»Amer. Jour. Med. Sci., 1885, lxxxix., p. 163. 

2 Ibid., 1899, cxviii., p. 265. 

3 Jour. mal. eutan., 1890. xi., p. 385. In Tenier's case the child was six 
months of age. Archiv, 1907, lxxxviii., p. 445. 

* Giorn. ital.. 1903, xxxviii., p. 99 (abstr. in Monatshefte, 1903, xxxvi., p. 674). 

5 J. C. D., 1908, xxvi., p. 321. 

8 Derm. Zeitschf., 1908, xv., p. 524. 

' Jacob Menzen, Tiber Gelenkerkrankungen bei, Archiv, 1904, lxx., pp. 239-262 ; 
Cutan., 1905, xxiii., p. 374. C. Adrian, Tiber Arthropathia psoriatica, Mitteil. aus 
den Grenzgebieten der Med. u. Chir., Bd. xl., Heft 2; Archiv, 1904, lxxii., p. 136. 



PSORIASIS. 283 

to fright, shock, and other neurotic conditions. 1 Acute toxaemias of 
various origins have been followed by an outbreak of psoriasis in 
individuals predisposed to the disease. Brocq and Ayriquae 2 in a 
careful study of the urine of psoriatic subjects found no constant 
results. 

The possible contagiousness of psoriasis is suggested by the 
clinical histories of a few cases. The absurd conclusions reached in 
some of these cases is well illustrated by Meneau where the disease 
is reported to have been induced by the use of a comb in common. 
Many attempts to transmit the disease by direct inoculation have 
failed, but Destot 3 apparently succeeded in inoculating himself from 
an infant with vaccinal psoriasis, and Lassar 4 succeeded in producing 
a disease of the skin in rabbits by rubbing into various portions of 
their bodies scales, blood, and lymph removed from psoriatic patches 
of a male patient. The disease thus induced is said to be capable of 
transmission to other animals. Campana, 5 Tommasoli, and other 
Italian observers have repeated these experiments, with the result of 
reaching the conclusion that psoriasis is produced by a parasite as 
yet unrecognized. 

The fact that psoriasis frequently has followed vaccination, 6 tat- 
tooing, 7 and other local injuries of the skin, has been held by some 
to be an argument in favor of the parasitic origin of the disease. It 
has long been known, however, that in psoriatic subjects lesions may 
be developed artificially in the lines of mechanical irritation. In 
this way, figures in the shape of anchors, crosses, hearts, etc., have 
been produced on the skin of psoriatic patients, one of whom has been 
ingeniously photographed by Fox, of New York. 8 

Gowers reports the artificial production of psoriasis by the inter- 
nal administration of sodium biborate. (Consult the section on Der- 
matitis Medicamentosa. ) Further evidence would be required to 
prove that these results differed to any appreciable extent from those 
recognized in any squamous dermatitis produced by an ingested drug. 

The distribution of psoriatic lesions suggests that the disease may 
be due largely to exclusion of sunlight from those portions of the 
body covered with the clothing and the hair. Certain it is that in 
exceptional cases only are the hands involved or is the face attacked 
at a distance from the line of the hairs upon the brow and bearded 
region (sides of the nose, cheeks, temples). It is likewise true that 
after exposure of affected areas to abundant sunlight, not only when 

1 Cf. Balzer, Annates, 1902, s. iv., iii., p. 639 ; Audry, Sour. Mai. cutan., 1900, 
xii., p. 345; and Weidenfeld, Archiv, 1903, lxiv., p. 359. 

2 Annates, 1906, 7, 5, 434-460. 

* Eeview of the case by Hallopeau, with discussion, Annates, 1901, s. iv., ii., p. 337. 

4 Deutsche med. Zeitg., 1885, No. 93. 

5 Clin. Dermosif., p. 1, 1906; B. J. of D., 1906, 18, 337. 

"Weinstein, Brit. Med. Jour., 1902, i., p. 271 {resume of twenty-four cases). 
Also Eiehlane. Monats., 1896, xxii., Feb. 

7 Bettmann, Munch, med. Wchnschrft., 1901, xliv., p. 1597. 

8 Photographic Illustrations of Cutaneous Diseases, New York. 



284 HYPEREMIAS AND INFLAMMATIONS. 

patients are treated intentionally by such exposures of the nude body 
to light in hospitals and in private practice, but in occupations which 
necessitate the same, beneficial results often are marked. 

The author 1 has elsewhere called attention, to the strong prob- 
ability that a species of light-hunger, affecting the habitually covered 
skin of man, is responsible for psoriatic lesions. The fact that the 
lower animals never exhibit the symptoms of the disease; that it is 
most prevalent in those countries and at those seasons of the year 
when sunlight is least abundant; and that the regions of the body 
specially attacked are those habitually either screened from the light, 
or exposed to it only irregularly and at intervals — these all point to 
the possibilities of operation of a cause set aside when radiotherapy 
or heliotherapy has been skillfully employed. 

In winter and in cold countries psoriasis is much more prevalent 
than in warmer seasons and climates. Kayser, 2 reports that in the 
tropics the subjects of psoriasis are few and the symptoms of the 
disease when they develop at all are " rudimentary," the typical 
eruption being scarcely ever produced. Finally in a considerable 
number of individuals, displaying through life unchanging patches 
in which the characteristic symptoms are the same year after year, 
the ailment would seem more properly to be classed with the deform- 
ities than with the diseases of the skin. 

Pathology. — The pathogenesis and the proper interpretation of 
the histopathological changes in psoriasis are unsettled problems. 
Many eases suggest a trophoneurotic or vasomotor origin; others ap- 
pear to be toxic and dependent on systemic conditions. The theory 
thai seems to be most attractive to investigators is that the disease is 
due to some as yet undiscovered parasite, implanted on susceptible 
soil. 

Lang 3 described a fungus which he named " epidermophyton," 
and which he believed to be the cause of psoriasis. If is findings 
once confirmed by Wolff and Eklund 4 are practically rejected by 
Neisser and others. Campa 5 recognized, with the Giernsa stain, round 
or oval bodies, with finely granular protoplasm, in the deeper epider- 
mis which resembled the Donovan-Leishman bodies. Weyl, who 
believes that psoriasis is due to an inherited weakness of the nerve- 
centres, regards Lang's "brood cells," as niyel in-like exudations. 
Ries 6 and others found the bodies described by Lang to be artificial 
products, not spores. It is possible that these bodies are the same 
as those which Crocker describes as " minute circular bodies which 
lie in loose clusters between the separate layers," and which by the 
aid of modern technique, Munro, 7 Kopytowski, 8 and others have 

1 Brit. Med. Jour., 1906, Oct. 6, p. 833. 

2 Geneeskumdig Tijdschrift vor Nederlandsch-Indie, 1907, xlvii., fasc. 5. 

3 Vierteljahr., 1878, xv., p. 346. 

4 Annates, 1885. 

5 Clin. Dermosif., 1905, 2 plates, B. J. D., 1905, xvii., p. 346. 

6 Vierteljahr., 1888, xv., pp. 521, 685, 871 (review of previous reports on path- 
ologv of psoriasis, with bibliography). 

'Annales, 1898, s. iii., ix., p. 961. 
8 Ibid., 1899, s. iii., x., p. 705. 



PSORIASIS. 285 

shown to be leukocytes situated between the lamellae of the psori- 
atic scales. 1 The two last-named observers state that accumulations 
of leukocytes which they call " dry abscesses " exist between the outer- 
most cells of the horny layer, before the appearance of other changes 
in the epidermis or corium. They look upon this fact as almost con- 
clusive evidence of the parasitic origin of the disease, but were 
unable to demonstrate the parasite. Robinson, 2 who studied lesions 
in all stages of development, Thin, Jamieson, Tilbury Fox, and others 
believe the process begins with hyperplasia of the rete which is fol- 
lowed by inflammatory changes in the corium. Other investigators 
of the earliest lesions, including Crocker and Verotti, 3 believe that 
the pathological process begins as a circulatory disturbance in the 
corium, and that the epithelial changes are secondary. 

The histopathology of the disease has been studied by many 
observers, including Hebra, Kaposi, Bosellini, Jarisch, and Schiitz. 
The corium, especially in the papillary and subpapillary portions, 
shows evidence of subacute or chronic inflammation. There are vas- 
cular dilatation, moderate oedema, and infiltration of polymorph- 
onuclear and small round cells, which is most marked about the 
vessels. The papillae are much elongated by the pressure from the 
interpapillary prolongations of the rete. The rete shows a marked 
hyperplasia, especially of the interpapillary processes, the number of 
cells immediately over the papillae, however, being fewer rather than 
in excess of the normal, a fact which accounts for the readiness with 
which the papillae bleed on removal of the scales. There is some 
intercellular oedema, the transitional layers are partially or wholly 
absent, and the process of cornification is incomplete, the outer cells 
retaining their nuclei. Bonnet 4 has recently recognized changes in 
the stratum corneum of the epidermis. 

The accumulation of leukocytes between the lamellae has already 
been mentioned. The presence of air between the cells forming the 
scales gives the latter their peculiar silvery-white appearance. 

Diagnosis. — The recognition of a pronounced case of psoriasis is 
made with ease, and often by those unskilled in cutaneous disease. 
As usual, it is the atypical form of the eruption that awakens doubt. 
The diagnostic features of the common types are summarized in the 
first paragraph under the heading of Symptoms. 

Eczema. — Eczema and psoriasis differ in a striking manner with 
respect to their sites of predilection and their extension from such 
sites in progressive cases. Eczema, from the head to the toes, elects 
the anterior surface of the body, the neighborhood of the mucous out- 
lets, the flexor faces of the joints and limbs, the crevices, folds, 
pockets, depressions, and protected angles of the skin. Psoriasis 
elects the posterior surfaces of the body, avoids the vicinity of the 

1 Sabouraud states that the scales of many superficial inflammations show leuko- 
cytes and coagulated serum between the lamellae (J. C. D., 1903, xxi., p. 61). 

2 N. Y. Med. Jour., 1878. 

3 Annales, 1903, s. iv., iv., p. '633 (bibliography of recent literature). 

4 Lyon med., 1907, fey, 24 ; p. ~ " 



286 HYPEE^MIAS AND INFLAMMATIONS. 

mucous outlets, spreads abundantly over the extensor aspect of the 
joints and extremities, and enjoys the regions of pressure and fric- 
tion, as the skin over the patella and the olecranon process of the ulna. 
Psoriasis, covering the vertex and scalp, lingers at the brow, where 
its scaly thatch stretches from side to side close to the line of the 
hairs, and creeps more indistinctly down the face on either side in 
front of the ear, reluctant to spread over the cheeks, nose, and lips. 
Eczema easily escapes from the scalp to the nose, lips, or chin, or 
lurks in the folds of the pinna of the ear. Psoriasis will cover the 
back and reach forward in front by almost symmetrically disposed 
parallels in the direction of the ribs, while eczema sweeps between 
and beneath the breasts or around the nipple. Psoriasis usually 
spares the hands and the feet, which eczema punishes. 

In individual patches eczema will be recognized by its severe itch- 
ing; by the scratching it excites; by the history of moisture, dis- 
charge, and crusting; by its ill-defined outline; by its asymmetrical 
disposition, except upon the similarly irritated hands and feet; and 
by the fewer, more yellowish, smaller, and less lustrous scales which 
characterize its squamous varieties. In squamous eczema, moreover, 
the areas are as a rule larger, more irregular in shape, fewer in 
number, and the loss perfectly defined outline does not show the Bmall 
round plaques which unite to form the larger psoriatic areas. 

Seborrhea, — This disease could only be confounded with psoriasis 
of the scalp; but the last-named affection is, in the vast majority of 
cases, exhibited also in patches upon other portions of the body on 
which seborrhoea is never seen. Seborrhoea of the scalp also occurs in 
usually diffuse forms, the surface beneath the crusts being rather 
anaemic and pallid in appearance, not bleeding readily. n< in psoriasis. 
The crusts, too, in seborrhoea, are distinctly fatty and greasy when 
rolled between the fingers, and have a dirty-yellowish hue, rarely 
recognized in the whitish scales of psoriasis. In psoriasis the hairs 
are not progressively loosened and gradually thinned as in seborrhoea. 
Lastly, seborrhoea may fringe the line of the hairs at the brow, and 
even form a band an inch or more in width, but the advancing border 
does not show the outlines of the small lesions of psoriasis. In 
seborrhoeic dermatitis the scales are smaller, greasy, and less abun- 
dant. The surface beneath is moist or oily, shows no bleeding points, 
and is less reddened than in psoriasis. The lesions are most numer- 
ous on the scalp, over the sternum, and between the scapulae, and 
rarely are found on the elbows and knees. 

Syphilis. — Psoriasis in many cases greatly resembles the squamous 
and papulo-squamous syphilides. The necessity for a clear recogni- 
tion of either disease occurring in suggestive patches is often of the 
highest importance. 

In syphilis the greatest aid will be obtained by a history in both 
sexes, of infection, adenopathy, and mucous patches; and in women 
of abortions, miscarriages, or stillbirths. Psoriasis is a singularly 
uniform disease; syphilis is decidedly multiform in its manifesta- 



PSORIASIS. ■ 287 

tions. Syphilitic patches are less symmetrical, more elevated at the 
edge, and the scales with which they are covered are fewer, smaller, 
and dirty-whitish rather than lustrous in color. Their circular out- 
line is often abruptly broken by gaps, with the result of producing 
semilunar and small arc-shaped segments. In syphilis the eruption 
is less generalized, and shares with other syphilodermata the brown- 
ish and purplish hues of the skin beneath, lacking the vivid redness 
and pinkish red of many non-syphilitic lesions. The scales of many 
of the syphilides which resemble psoriasis partake of the character 
of crusts, being agglutinated by pathological exudations from the 
patch; they are rarely so exclusively squamous as in psoriasis. In 
syphilis the tendency of the patch is to exhibit an affected surface 
somewhat beyond the line of the scales ; in psoriasis the scales more 
frequently reach beyond the border of the affected epidermis beneath. 
The squamous syphiloderm of the palms and soles often occurs only in 
these localities. Psoriasis is extremely rare in such situations, and 
is seldom limited to these regions exclusively. A psoriasiform circlet 
limited to the region of the mouth, nose, or chin will generally prove 
to be syphilitic. The disease which has for a long time persisted 
in the production of squamous patches can generally be demonstrated 
to be psoriasis, as syphilis changes its type in the course of months. 
Pityriasis Rosea. — In this disease the patches are more oval than 
circular, the scales much finer, and on their removal no bleeding 
points are seen. The centre of the patch is usually tawny or salmon 
colored. The disease is much more superficial, less inflammatory, 
and much more rapid in its career than psoriasis. Complete involu- 
tion is accomplished usually in a few weeks and recurrences are rare. 
Lichen Planus. — The primary lesions in lichen planus are very 
minute, flat, angular papules which as individuals rarely become as 
large as the cross-section of a small pea. The larger areas are formed 
always by grouping and coalescence of small papules. Instead of 
presenting distinct scales, the lichen planus papule is covered with a 
thin horny layer giving the papule a glazed or varnished appearance. 
There is a tendency to linear arrangement of the lesions, and when 
these coalesce to form larger areas the latter are commonly linear or 
angular in outline. The larger papules and patches in lichen 
planus have a characteristic purplish or violaceous hue, which never 
is seen perfectly in psoriasis. The favorite sites of lichen planus are 
the flexor surfaces of the wrist and forearm, and the leg above the 
ankle. It is rarely conspicuous on the elbows, knees, and other 
regions commonly affected by psoriasis. 

Pityriasis rubra pilaris (lichen ruber acuminatus) is a compara- 
tively rare disorder and has for primary lesions fine, pointed, scale- 
capped papules which do not enlarge peripherally, but form larger 
areas solely by the coalescence of many small papules, some of which 
can be demonstrated at the borders of the larger areas. The char- 
acteristic circular areas and the typical scales of psoriasis are want- 
ing, and there is frequently some impairment of the general health. 



288 HYPEREMIAS AND INFLAMMATIONS. 

In exceptional instances, however, the two disorders may progress to 
the formation of a generalized or universal exfoliative dermatitis, in 
which it would be impossible from clinical or histological examina- 
tion to state in which of the two disorders the final condition orig- 
inated. 

Lupus Erythematosus. — In the rare cases in which psoriasis ap- 
pears on the face without characteristic lesions elsewhere, the picture 
might suggest an atypical lupus erythematosus with scattered lesions. 
The scales of lupus erythematosus, however, are scanty, firmly ad- 
herent, yellowish, and attached to the orifices of the sebaceous follicles. 
There is also a bluish and violaceous tint to the red patch of lupus 
erythematosus, and lesions which have undergone involution may 
leave the characteristic atrophic or stippled scars. 

Tinea Circinata. — In ringworm of the body there are as a rule 
in northern climates fewer patches, and these are more distinctly 
circular. They rarely attain a diameter of two inches without show- 
ing a clearing centre and a slightly elevated border covered with fur- 
furaceous scales. The discovery of the fungus will establish the 
diagnosis. 

Favus of the scalp might be mistaken for psoriasis of the same re- 
gion, but the occurrence of sulphur-colored, cup-shaped crusts, the 
existence of the parasite, the lustreless and brittle condition of the 
hairs, the presence of irregular areas of alopecia or of reddened scar- 
tissue, and a possible history of contagion will insure identification of 
favus. In psoriasis, too, the hairs usually are attached firmly in their 
follicles, while they are loosened in favus. 

Treatment. — Though it is unusual t<> see cases in which psoriatic 
Lesions cannot be removed temporarily, the disease "tun returns, and 
is exceedingly resistant to treatment. A method which is successful 
in a given case may fail in the next; indeed, a method which gives 
prompt relief in a given case at one time may fail utterly in subse- 
quent attacks of apparently the same nature. The involution of the 
disease under treatment is, as a rule, not rapid, and a chosen method 
should not be abandoned until it has been given a thorough trial. 

Systemic Treatment. — The general condition of each patient must 
be ascertained and given due consideration in the treatment. There 
are many cases of psoriasis in which treatment will prove unsuccess- 
ful until an accompanying systemic disturbance is recognized and 
given proper attention. On the other hand, when the health, habits, 
and surroundings of the patient are normal, it is better to give local 
treatment a thorough trial before resorting to arsenic and other drugs 
which are supposed to have a specific action. 

When, as in the amemic, the debilitated, the neurotic, the gouty, 
or the rheumatic, a systemic disorder is demonstrated, the indica- 
tions for treatment are clear. The doubtful cases are those in which, 
after careful study, no definite systemic disturbance is discoverable. 
Psoriasis occurs not infrequently, and is often especially persistent 
in individuals who may be classed as fleshy, plethoric, or overfed, 



PSORIASIS. 289 

without other evidences of ill-health. In such cases a restricted diet, 
increased elimination, with possibly the administration of an alkali, 
are effective aids to local treatment. Some writers advocate such 
measures in all cases unless they are contraindicated by anaemia or 
other conditions calling for increased nutrition of the body. 

The diet should be simple and nutritious. In most instances 
meat, sweets, pastry, hot breads and hot cakes, and highly seasoned 
foods should largely or wholly be avoided. Vegetables and fruit may 
be eaten freely. In acute conditions, when the subjective sensations 
are annoying, the diet should be practically that recommended for 
acute stages of eczema. Alcohol, coffee, tea, and tobacco should be 
interdicted or used in moderation only. Passavant, however, claims 
to have cured himself and others by an exclusive diet of meat. 

Among the remedies supposed to have a specific action upon psori- 
asis, arsenic enjoys the highest rank. In some cases prolonged ad- 
ministration of arsenic gives temporary or even permanent relief; 
in a large proportion of patients, however, carefully selected as fit 
subjects for this therapeutic agent, it will prove utterly valueless even 
in the most skilled hands. Moreover it is not possible to determine 
in advance what cases will yield to arsenic, and even with a given 
individual the drug may be of great value at one time and at another 
without effect. Eecognizing these facts, the wisest course is not to 
employ arsenic at first, but to delay its administration in any case 
until local treatment has been given a thorough trial. 

Arsenic is valuable chiefly in persistent cases in which the lesions 
have ceased to enlarge. It is unsuited for all cases of psoriasis occur- 
ring with rather acute symptoms, such as subjective sensations and 
unusually vivid redness of the patches. It should not be given when 
the disease is in process of evolution, and, therefore, not in psoriasis 
punctata and guttata, unless the lesions have long been limited to 
patches of the sizes to which these names are given. For the same 
reasons it is often objectionable in the psoriasis of the young, for 
though the drug is usually well tolerated in early periods of life, it is, 
unfortunately, in the young in whom the disease is also most often 
encountered in its progressive stages. 

The following rules for the administration of arsenic are in gen- 
eral to be observed : It should be given with or immediately after the 
ingestion of food, so that it may be commingled with edible substances 
in the stomach. It should be given at first in small doses which are 
to be increased cautiously. The possibility of the production of toxic 
effects should be remembered, and on their appearance the remedy 
is to be given in a smaller dose, and not completely discontinued unless 
such a course be imperative. 

Individuals not infrequently possess a marked idiosyncrasy 
against arsenic. Cases are seen also in which the administration of 
arsenic for psoriasis is followed by acute exacerbation of the disease 
with decided aggravation of the subjective symptoms. Even in cases 
in which arsenic ultimately proves of value, no results may be 

19 



290 HYPEREMIAS AND INFLAMMATIONS. 

achieved for a number of weeks. The value of arsenic, therefore, in 
a given case cannot be tested with a course of less than three months. 
The prolonged use of large doses of arsenic has been followed in 
many instances by palmar and plantar hyperkeratosis, and in a few 
instances by verrucous growths, some of which have become epithelio- 
matous. 1 Continued use of arsenic is capable also of producing 
more or less generalized pigmentation with or without a diffuse hy- 
perkeratosis. 

The preparation of arsenic usually employed is Fowler's solution, 
the exhibition of which should always be begun in doses of from ^ 
minim (0.033) to 3 minims (0.20), this amount to be contained in a 
solution of fixed and relatively lar^e dose, such as a teaspoonful of 
infusion of peppermint, wine of iron, dilute syrup of gentian, of 
orange-blossoms, or compound tincture of cardamom with water. 
When only remedial effects are obtained, such as diminution of the 
scaliness, the dose may steadily bo continued without change for long 
periods of time, and usually with advantage for some time after the 
symptoms of the disease have disappeared entirely. When, without 
the production of toxic effects, the eruption seems unaffected by 
treatment, the arsenic may cautiously, and always under the direction 
of the physician only, be pushed until 10 or more drops of Fowler's 
solution are administon-il at a dose. Other preparations of arsenic 
may be used. A solution of sodium arsenate is preferred by Stel- 
wagon in cases of weak digestion. Arsenous acid may be given in 
doses varying from Ko to %n (0.0016—0.0033) grain in pill or 
tablet, or in the form of the Asiatic pill, the formula for which is 
given in the section on General Therapeutics. Tins pill is less likely 
to be tolerated well than Fowler's solution, but cases are on record in 
which a psoriasis which proved rebellious under the administration 
of other forms of arsenic, yielded to the Asiatic pill. 

Sodium cacodylate, an organic compound of arsenic containing 55 
per cent, of arsenous acid, has been recommended and used largely 
by some French dermatologists. It is supposed to disturb digestion 
less and to be comparatively free from the danger of producing 
toxic symptoms. The dose recommended is from | to 3 grains 
(0.033-0.2), three times a day. That it is not safe in large doses 
was demonstrated by the case of Murrell, 2 who gave a patient 1 
grain (0.06), three times a day, until, on the eleventh day, there 
suddenly appeared serious symptoms of intoxication. Dermatitis 
following its use is reported by Balzer and Griffin. 3 We have used 
the drug in a few cases in doses varying from tV to ^ (0.004-0.033) 
grain, three times a day, but have not found it of greater value than 
the other preparations of arsenic. 

Satisfactory results often follow the internal administration of 

1 Cf. White and Hartzell, loc. cit. The author has had several such accidents 
brought to his attention. 

1 Lancet, 1900, ii., p. 1923. 

3 Annales, 1897, s. iii., viii., p. 732. 



PSORIASIS. 291 

mercurous iodide in 5 grain (0.013) doses after meals. The remedy 
is given, not in cases in which a syphilitic taint is suspected (for 
psoriasis is not a manifestation of syphilis), but as an alterative. 
It is believed to be effective in consequence of its special effect on 
the liver. In some patients it seems to have little value. Carbolic 
acid and nitric acid, the last-named in the largest medicinal doses, 
are highly extolled by some authors. 

Crocker advises the use of sodium salicylate and salicin in all 
forms of psoriasis, but especially during periods of active develop- 
ment of the disease, when arsenic usually is harmful. I have 
found these remedies of value in a number of cases. Salicin is the 
better of the two preparations, as it interferes less with digestion. 
It may be given in doses ranging from 10 to 20 grains (0.66-1.33), 
three times a day. Haslund recommends potassium iodide, increased 
from the smaller to the largest tolerated doses. As many as 600 
grains (40.) of the iodide have been administered by this method per 
diem; it is of occasional service. The wine of antimony in 5 to 10 
minim doses (0.33-0.66) ; chrysarobin, i grain (0.01) rubbed up 
with sugar of milk, three times daily ; potassium bromide and sodium 
iodide have also been administered with reported success. 

In plethoric or rheumatic patients local treatment often is ren- 
dered more effective by the internal administration of alkalies such as 
liquor potassae, potassium citrate or acetate, or sodium bicarbonate in 
doses of from 10 to 30 grains (0.66-2.), taken with large quantities 
of water three times a day. In the gouty state with excess of urates 
in the urine Robinson advises: 

$ Potass, acetat., 5J; 30 

Spts. ffither. nit., fjss; 15 

Vin. colchici, f 3ij ; 8 

Syr. aurantii, fgjss; 45. 

Sig. A dessertspoonful three times daily in water after meals. 

As to the other remedies employed internally for the relief of the 
malady, a very fair estimate of their value can be made by remem- 
bering that arsenic is superior to them all. Phosphorus, tar, copaiba, 
oil of turpentine, cantharides, colchicum, and pilocarpine have at 
times a feeble transitory influence over the patches of the eruption, 
but their employment will disappoint far more often than satisfy. 
The treatment of psoriasis by the administration of extract of the thy- 
roid gland practically is abandoned as fruitless of desirable results. 

External Treatment. — The influence of climate in inveterate psori- 
asis should never be ignored. Many patients who suffer from re- 
peated relapses of the disease are worse in winter, and are either 
better or entirely free from the eruption in summer. In mild cli- 
mates in which the temperature is uniformly registered at or near a 
point of maximum comfort for the skin this disease is both infrequent 
and less severe. Given an equable climate many patients obtain 
prompt relief at the seashore, while others improve rapidly under 
ihe influence of the dry atmosphere of higher altitudeSr The major- 



292 HYPEREMIAS AND INFLAMMATIONS. 

ity of patients with psoriasis, however, are unable or unwilling to 
seek a change of climate for the relief of a disease which at worst 
is an annoyance. In cold and changeable climates some patients 
add greatly to their comfort by varying their dress to meet the exigen- 
cies of the weather, thus keeping the skin at as even a temperature as 
possible. When there is much itching, cotton or linen underwear 
next the skin is imperatively required. 

The local treatment of psoriasis requires patience, care, and a 
certain degree of skill. In a large majority of cases a remedy can be 
found which, when applied with proper care and persistence, will 
remove the lesions completely. This result, however, does not insure 
the patient against recurrences of the disease. The first indication 
to be met is the complete removal of the epidermic scales from the 
patches; their removal is accomplished in various ways. It is pre- 
ferable to secure first their maceration in some fatty substance, such 
as one of the oils, or glycerin, or vaselin, after which the scales may 
be washed off with the aid of soap and water, the patient being given 
a general bath if the eruption be extensive. After such bathing a 
salicylated salve (ten to twenty grains (.66-1.33) of the acid to the 
ounce (30.) of cold cream salve or Lassar paste may be applied to the 
patches from which the scales have been removed. If the eruption 
be localized, these oily or fatty substances may be spread upon pieces 
of lint or cotton, and thus be retained in contact with the skin by a 
bandage. The scales may also be removed rapidly with a dermal 
curette, if they occur in few patches, or if the patches are to be 
found in totality or in part upon some portion of the body in which 
the disfigurement demands special attention, as upon the forehead 
and the cheeks. The squamous masses are also removable with water 
alone, as after maceration of the skin in a bath, or after a profuse 
diaphoresis, or even after moderate exudation of sweat, if evapora- 
tion of the latter be prevented by covering the affected part with oiled 
silk or with rubber tissue. Usually there is no difficulty in removing 
the scales, patients often declaring that they can themselves cleanse 
the surface. They ask to be shown how to prevent the recurrence of 
the desquamation. 

Exposure of the skin to solar light is of great value in many cases. 
Domenci, 1 decribes the case of a man 20 years of age who had suf- 
fered from psoriasis for eighteen months. The patient was improved 
after twenty minutes exposure to the sun's rays. In one month the 
scales ceased to form and at the end of the season, he was completely 
relieved. There was no recurrence for one year. I have found 
some patients who would free themselves from the disorder by giving 
the affected parts a sun-bath daily or several times a week. 

Baths play an important part in the subsequent treatment of the 

disease. They may be employed, as by Hebra, so that the patient 

remains in the water for from four to eight hours in the day; or be 

medicated by the addition of sulphur, tar, or other substances, so as 

1 Gazz. d. Osped., 1908 (abstr. in Derm. Centralb., 1908, xii., p. 15). 



psoriasis. 293 

to combine a medicative with a macerative effect. In private practice 
these baths are much less available than in hospitals. When the erup- 
tion is generalized and an excessive macerative effect is desired an 
undershirt and drawers, made of soft rubber cloth, may be worn by 
the patient for several hours of the day. The sweating is often pro- 
fuse, and is debilitating to such an extent that the psoriatic skin will 
rarely tolerate the treatment for an entire day, or even for that part 
of the day in which active labor is performed. By this sweating 
alone it will at times be found possible to secure complete disappear- 
ance of the patches. 

In other more obstinate cases, or in those in which for any reason 
vigorous treatment is indicated, as upon the scalp and face, sapo 
viridis may be employed with advantage in the soap-and-water treat- 
ment. The spiritus saponis kalinus, 2 ounces (60.) of the soap to 1 
ounce (30.) of alcohol, may be rubbed briskly over the patches with 
the aid of a piece of flannel or a sponge, and then immediately be 
washed off with the oil and scales in a surplus of hot water, or be 
left for a time in contact with the part. Hebra and Kaposi employed 
a species of soap-paste, made by rubbing into each patch a small 
quantity of green soap to which a little water is added until the 
proper consistency is obtained. These inunctions are repeated twice 
daily for six days. The epidermis becomes brownish-colored, and 
in three or four days afterward it exfoliates in lamellae ; then a gen- 
eral bath cleanses the surface. In the French hospitals a somewhat 
speedier method is pursued. On the evening of the first day the 
patient is anointed with green soap, which is retained upon the skin 
during the night. In the morning he takes an alkaline bath, and 
immediately after is thoroughly anointed with lard. This course is 
repeated on the second and third days, after which the patient is 
usually ready for topical medication of the diseased parts. 

For the more obstinate cases in which exfoliation of the epidermis 
is not readily induced more energetic measures have been adopted, 
such as the local use of salicylic acid in alcohol, 1 drachm (4.) to 4 
ounces (120.), caustic acid and alkalies, scrubbing the patches with 
nail-brushes, floor-brushes, etc., and the use of clean white sand. 

Once ready for topical medication, the patches may be subjected 
to the local action of the remedy selected for the relief of the disease. 
The choice of a vehicle for the application of remedies is a matter of 
importance. For hospital patients, moderately soft ointments, such 
as lanolin or lard, with or without the addition of cold cream oint- 
ment, may be rubbed into the patches, which may then be covered 
with cloths spread with more of the same ointment. For such cases, 
an ointment which keeps the surface soft and favors penetration of the 
remedies is usually more rapidly effective than the drier pastes, espe- 
cially when there is much scaling and infiltration. When the patches 
are irritated moderately, and in acutely spreading areas, the protec- 
tion afforded by the paste is often of more value than the closer con- 
tact of the remedy with the lesion permitted by the soft ointment. 



294 HYPEREMIAS AND INFLAMMATIONS. 

But the majority of patients with psoriasis are unable to give the time 
necessary for hospital treatment, and remedies must be chosen which 
will not interfere with the usual vocation of the individual. For 
the scalp and other hairy parts, vaselin, or equal parts of vaselin, 
lanolin, and olive oil, are convenient ointment-bases. For the face 
and hands a moderately soft ointment may be used as directed above 
for hospital cases. When the occupation of the patient will permit, 
the lesions may be kept covered with a thin coating of the same oint- 
ment during the day, or this may be removed entirely and the patches 
protected with a tragacanth-vamish (see section on General Thera- 
peutics), which in turn must be washed off at night before applying 
the ointment. For covered portions of the body, the most convenient 
base is a paste, equal parts of vaselin, lanolin, zinc oxide, and talcum 
making a good combination. When the lesions are few in number, 
the paste may be spread on a cloth and applied. In more extensive 
cases the paste may be spread in a thin layer over the patches, which 
then are covered freely with any simple powder. This is patted on 
with the hand or with cotton until a dry surface is formed which does 
not adhere to the clothing. The underclothing next the skin should 
be of soft cotton. 

For circumscribed areas flexible collodion, liquor guttae perchse 
(traumaticin) holding in solution the remedies to be employed, or 
medicated plasters are more convenient and cleanly than pastes or 
ointments. 

Salicylic acid, in paste, ointment, or plaster, in strengths varying 
from 2 to 20 per cent., is often effective, and is free from the dis- 
agreeable and even dangerous properties of some of the Btronger 
drugs. For the face, BCalp, and hands there is no better remedy in 
the majority of cases than ammoniated mercury in 2 to 20 per cent. 
ointment or paste. This remedy is cleanly and usually causes the 
lesions to disappear; but it cannot be used over large areas without 
danger of absorption and constitutional symptoms. 

A drug of great value in the treatment of psoriasis is chrysarobin. 
This is a crystalline powder of the color of old gold, insoluble in 
water, but is dissolved readily in hot alcohol, chloroform, benzol, 
vaselin, and hot fat. Tt is derived from the "Goa powder" of the 
East Indies, or the " araroba powder " of Brazil, the employment 
of which in psoriasis was recommended first in 1878 by Squire, of 
London. The drug may be applied in strengths varying from 2 to 
40 grains (0.13 to 2.66) to the ounce (30.) of ointment, paste, plas- 
ter, collodion, or liquid gutta-percha. It is used occasionally in 
greater strength, but with pure specimens it is liable in larger pro- 
portions to produce disagreeable effects, commonly manifested in a 
hot, itching, swollen, irritable, and erythematous or darkly stained 
skin, stretching with tolerable uniformity in every direction from the 
surface of application. Even in the strength named above it is neces- 
sary to begin its use with caution, testing it by application first to a 
limited area of integument. The dermatitis produced by the drug 
usually subsides in a few days. 



PSORIASIS. 295 

When chrysarobin produces its most brilliant effects the psoriatic 
patch, previously denuded of its scales, assumes a whitish and normal 
aspect, contrasting thus somewhat remarkably with the chocolate or 
brownish-black discoloration of the stained skin at the periphery. 
This discoloration, when produced either by the ointment directly 
or by a frequent transfer of its ingredients to other parts by the 
medium of the clothing and the hands, involves also the nails, the 
hair, and the undergarments of the psoriatic patient. Its employ- 
ment upon the face and the scalp is thus largely interdicted. The 
staining of the skin and its appendages disappears in time, but always 
slowly. 

Chrysarobin is of value chiefly in persistent cases in which milder 
remedies fail. In the acute forms there is great danger of produc- 
ing dermatitis with the drug. When the lesions are numerous, or in 
large areas, the most rapid results are obtained by applying the remedy 
in the form of a soft ointment 20 to 60 grains to the ounce (1.33- 
4. to 30.) which may be rubbed thoroughly into the patches once or 
twice a day. The surplus ointment may be wiped off and the skin 
covered with a dusting-powder. Used in this way the drug stains the 
underclothing and the skin and is more liable to produce a dermatitis. 
For circumscribed areas, chrysarobin may be applied in liquor guttse 
perchse (traumaticin). After the scales have been removed thor- 
oughly, a film of traumaticin is applied with a brush or a swab, and 
allowed to dry. Several coats may thus be put on within a few min- 
utes. The dressing usually will stay in place several days. When 
it becomes loose, it should be removed and a fresh dressing applied. 
Instead of traumaticin, collodion may be used. An effective com- 
bination, suggested by Fox, is 10 parts each of chrysarobin and 
salicylic acid, 15 of sulphuric ether, and 100 of flexible collodion. 
The following method, first suggested by Besnier, brings the drug in 
closer contact with the lesions and gives more rapid results : a solution 
of chrysarobin in chloroform, 20-40 grains (1.33 — 2.66) to the 
ounce (30.), is applied to the patches. The chloroform rapidly 
evaporates, leaving the powder adhering to the surface. When a 
sufficient quantity has thus been applied and is thoroughly dry, col- 
lodion or traumaticin is allowed to flow over the patch to produce a 
protecting film. Instead of dissolving the chrysarobin in chloro- 
form, it may be mixed with water to form a paste and applied in the 
same manner. Fox uses chrysarobin in a 50 per cent, aqueous solu- 
tion of ichthyol. After painting it on the patches and allowing it to 
dry, a dusting-powder may be used. 

Hallopeau reports cases in which the lesions disappeared when 
kept covered with unmedicated traumaticin. 

Tar is among the most valuable remedies in the local treatment 
of psoriasis. It will, however, accomplish the result desired only 
when so applied that it is tolerated well by the skin. In very young 
patients, as also in those whose skins are tender and irritable, or those 
suffering from any of the acute phases of the disease, it may prove 



296 HYPEREMIAS AND INFLAMMATIONS. 

decidedly injurious. The rule should be always to employ it at first 
tentatively over a relatively small portion of the affected surface, 
upon which the medicament should remain for several hours, as tar 
will not in all cases promptly produce its injurious effects. These 
effects are, subjectively, a sense of heat and pain ; and, objectively, 
heat to the touch, redness, and tumefaction. Often black puncta are 
visible when the tar is lodged in the orifices of the cutaneous follicles, 
simulating thus the " black head " of the comedo, a condition termed 
by Hebra "tar-acne." 

Fix liquida, oil of cade, or preferably oleum rusci may be em- 
ployed in the form of a salve, 1 drachm (4.) of either to the ounce 
(30.) of lard or other fatty basis (lanolin, vaselin, etc.). A thin 
stratum of this ointment several times in the day or merely at night 
may be painted over or well rubbed into a patch denuded of scales. 
In Vienna a still more energetic effect is secured by using soft soap 
freely over the patches while the patient is in the bath, then anointing 
him with tar, and finally returning him to the bath, in which he re- 
mains for from four to six hours. For localized eruptions, green soap 
in combination with tar and alcohol serves a useful purpose, either in 
the proportion of equal parts of the three ingredients, or by combin- 
ing them in other proportions, as, for example : 

IJ Saponis mollis, 

01. rusii, i 

Glycerin., J 

Ol. rosniarin., 

Spts. vin. rectif., 
Sig. For externa] nse. 

Other combinations of service are the "liquor picis alkalinua," 
the formula for which is given in the chapter on Eczema; or Wilkin- 
son's salve, as modified by Hebra, the latter combining the remedial 
effects of sulphur, tar, and soap, as follow-: 



3»'; 


120| 


aa 5J; 


30 1 


3JB8 ; 
Osa; 


61 

iMil' 



$ Sulphur, snblimat., "> 
Ol. rusci (crud. vel. rectif.), J 


aa ^ss; 


15| 


Saponis mollis, | 
Adipis, j 


ai 5J: 


30 1 


Cret. pneparat., 


3ijss; 


3|: 


Sig. Wilkinson's salve, modified. 







3|33 M. 

Where the sensitiveness of the skin to the action of tar has not 
been tested, or when the skin is particularly tender, 1 a small quantity 
of the Wilkinson salve may be added to any simple ointment, or 
Spender's ointment of tar (see the chapter on General Therapeutics) 
may be substituted; afterward 1 drachm (4.) of the oil of tar, or of 
oleum rusci, to the ounce (30.) of oil of almonds or of alcohol, may 
be employed. 

When toleration is established the tar may be rubbed over the 

patches in a pure state with a stiff brush, a procedure preferred in 

some parts of Germany, after which the patient either remains for 

1 Cf. Burnet, J., Treatment of psoriasis in children, Merck's Arch., 1908, x., 171. 



PSORIASIS. 297 

some hours in bed, or is powdered with soapstone and bandaged with 
flannel, so that when the clothing is replaced it may not adhere to the 
tar. Naphtalin, ichthyol, and carbolic acid operate in psoriasis in 
the same way as the tars, but are decidedly inferior to the latter. 

Absorption of any tarry compound applied externally may result 
in general toxic symptoms, including fever, vomiting, diarrhoea, stran- 
gury, or the elimination of the toxic agent in secretions which are 
blackened by its presence. These symptoms are usually relieved in 
from twenty-four to forty-eight hours after discontinuance of the 
drug. 

Hartzell 1 has injected atoxyl in the gluteal muscles in the case of 
eight patients who were psoriatic, with apparent benefit. 

Pyrogallol, first suggested as a remedy for psoriasis by Jarisch, 
is inferior to chrysarobin. The fact that several deaths have been 
reported as consequent upon the use of this acid deters many from 
making trial of it in a painless and merely disfiguring disease. It is 
used in a 10 per cent, vaselin ointment, is effective though less rapid 
in effect than chrysarobin, is cheaper, is odorless and painless, and 
it discolors to a less extent the sound skin. Both remedies are cap- 
able of being absorbed from the skin-surface, and of producing con- 
stitutional symptoms (pyrexia, strangury, and blackish evacuations) ; 
but in the case of pyrogallic acid only have fatal results followed. 

Kaposi 2 was the first to employ beta-naphtol (C 10 H s O) in pso- 
riasis, as also in eczema. It may be applied in alcoholic solution. 
Following the employment of a 15 per cent, ointment the author 
reported speedy disappearance of psoriatic patches. It did not stain 
the skin, hair, or nails. 

Crocker, of London, similarly uses thymol in ointment, -J scruple 
to | drachm (0.66-2.) to the ounce (30.) ; and Williamson advises 
turpentine, 2 drachms (8.) to the ounce (30.) of olive-oil, with the 
odor corrected by the oil of lemon. 

Circumscribed areas have been treated successfully by the daily 
application of compresses wet in a 1 : 300 or 1 : 200 solution of potas- 
sium permanganate (Hallopeau 3 ), or in 70-90 per cent, alcohol con- 
taining 2 per cent, of salicylic acid (Lau 4 ). 

For inveterate cases, Unna and Dreuw recommend the following : 

fy Acid, salicylic, 3ijss; 10 1 

Sig. For external use. 

1 J. A. M. A., 1908, vii., 18, 1482. 

2 Wien. med. Wchnschrft., xxxi., pp. 617, 641, 681. 

s Annales, 1902, s. iv., iii., p. 518. 

* Semaine med., Sept. 13, 1899. 



298 SYPEBMMIAS AND INFLAMMATIONS. 

Blaschko 1 finds Rochard's formula of value in stubborn cases 
which do not yield to chrysarobin: 

$ Iodi pur., gr. x; 166 

Hydrarg. chlorid. mitis, gr. xxvj ; 17 

Vaselin, vel adipis, q.s. ad ^iij 5ijss; 100| M. 

These stronger applications must all be used with caution, and any 
dermatitis produced should be treated with soothing ointments. 

The nitrate, as well as the iodides and oxides, of mercury is ap- 
plied by many practitioners in the form of ointment to patches of 
psoriasis usually few in number and limited in extent. The action 
of these agents, however, is inferior to that of those already named ; 
and the range of their availability being limited, they should be 
esteemed lightly in the topical treatment of the disease. Other arti- 
cles more recently vaunted in the external treatment of psoriasis are : 
thilanin, which seems to possess some value; hydracetin; cacodylic 
acid; rufigallic acid, 10 per cent, in unguent form; cupric oleate; 
anthrarobin; and gallacetophenol, 5 to 10 per cent, in salve or in 
traumaticin. 

Radiotherapy is a clean and efficient method of local treatment in 
psoriasis. In the majority of instances psoriatic lesions disappear 
with more certainty under X-rays than with other local measures. 
The rays should be employed with great caution, and a dermatitis 
should not be induced. Few exposures of moderate intensity suffice. 
The psoriatic skin responds readily to the treatment but may become 
the seat of dermatitis even when exposed to an amount of rays 
which would be considered moderate in other conditions. Telan- 
giectasia is prone to develop in areas in which an active dermatitis has 
been induced. Recurrence of lesions happens after radiotherapy as 
after other methods of treatment. Great caution is necessary in 
treating a series of recurrences, especially if the recurring lesions 
occupy areas formerly involved. Radiotherapy is not recommended 
in psoriasis of the scalp, and should be the method of choice only in 
selected cases. 

Prognosis. — The permanent relief of psoriasis is not insured by 
any treatment of a grave case, though hundreds of patients are per- 
manently relieved by even the simplest treatment. The disease often 
recurs, and may do so repeatedly for the greater part of a lifetime. 
Permanent relief, therefore, should be neither predicted nor prom- 
ised in any case. Once relieved, it should be the aim to guard against 
all possible recurrences. After relief of any obstinate or recurrent 
attack, as also in all inveterate cases, the prognosis is greatly im- 
proved by removal to a climate suitable for the psoriatic patient. 

Recent Literature. 

Herxheimer, Karl: Uber ausserliche Behandlung der Psoriasis, Dtsch. med. 
Wochenschr., 1904, No. 5. 

Sylvester: A case of psoriasis cured by laparotomy and currettage, Boston M. 
and S. Journ., 1906, pp. 154, 583. 

1 Archiv, 1901, lvi., p. 253. 



P1TYB1ASIS BOSEA. 299 



PITYRIASIS ROSEA. 

(Pityriasis Maculata et Circinata, Herpes Tonsurans Macu- 
losus, Pityriasis Circinata. Fr., Pityriasis rose be Gibert, 
Pityriasis ctrcine et margine, Pityriasis dissemine, Pity- 
riasis RUBRA AIG-U, RoSEOLE SQUAMEUSE (ChAPARd).) 

Pityriasis rosea is a mild febrile disorder of specific character and 
determinate course, in which appears a cutaneous, usually symmetric- 
ally disposed, exanthem in the form of multiple, circumscribed, 
superficial, roundish or oval-shaped, yellowish and rosy patches, cov- 
ered with fine scales and seated for the most part on the trunk. This 
disorder was recognized and described first by Gibert, 1 and later by 
Bazin, Horand, Duhring, 2 and others. 3 

Symptoms. — The subjects are commonly young adults but the 
disease is seen in children and in middle life in both sexes. The out- 
break of the malady may be preceded for a variable time by languor, 
lassitude, inappetence, or a feeling of chilliness. Occasionally the 
first noticeable symptom is the occurrence of mild fever, the body- 
temperature rarely rising above 102° P. There may be slight swell- 
ing of the submaxillary glands and of those of the neck. General 
adenopathy is reported. In acute cases there may be distinct con- 
gestion of the fauces. 

In some, Brocq 4 believes in all, cases the general outbreak is pre- 
ceded for a week or ten days by a single lesion situated usually at 
the side of the trunk. Searching the surface of the skin after the 
eruption is fully developed, this " primary lesion " may often be 
recognized as the largest, most conspicuous, and most brilliant in hue 
of all the patches exposed to the eye. The eruption, however, often 
escapes recognition for a time after its appearance on account of its 
sparseness or the trifling degree of pruritus it arouses. When fully 
developed, it is characterized by the conspicuous appearance over 
large surfaces of the trunk, especially upon the integument covering 
the clavicles, the ribs, and the scapulae, rarely on the exposed face and 
hands, of numerous pinhead- to small-coin-sized, circumscribed, round- 

Neuberger: Bemerkungen zur Psoriasistherapie, Derm. Zeitschrift, 1906, xiii., 
p. 172. 

Pautrier, L. M. : Treatment of psoriasis by swathing with ointment (Maillots 
de pomade), La Presse Medicale, 1905, p. 683. 

Cerulli: Effeti della eura psoriasis, Giorn., 1905, Fesc. 4. 

Lengefeld: Die Behandlung der Psoriasis vulgaris mit Chrysarobin-Dermasan, 
Wiener klin.-therap. Wochenschr., 1906, No. 6. 

Abraham: Psoriasis and its management, Brit. Med. Jour., 1906, April 14th. 

Saalfeld: Zur Behandlung der Psoriasis, Ther. Monatsh., 1908, No. 1. 

Gerstle, Eugen: Uber Psoriasis vulgaris und deren Behandlung, Inaug. -Dissert. 
Munchen, 1902. 

Joseph, Max: Derm. Centralb., 1906, p. 358. 

1 Traite pratique des maladies de la Peau, Paris, 1860, i., 402. 
2 Amer. Jour. Med. Sci., 1880, lxxx., p. 359. 

3 Moingeord, These de Paris, 1889; Chapard, These de Paris, 1885: Thibierge, 
La Prat. Derm., 1902, iii., 894, with colored plate. 
* Annales, 1887, s. ii., viii., p. 615. 



300 HYPEREMIAS AND INFLAMMATIONS. 

ish or oval-shaped, slightly elevated, macular or maculo-papular lesions 
which are fitly designated by Thibierge as " medallions." These 
lesions may be discrete, closely set, or confluent, and instead of being 
elevated may be either on a level with the general surface or slightly 
depressed, with an annular border. They are dry, covered with fur- 
furaceous rather adherent scales, and vary in color from a yellow or 
tawny (chamois-skin) shade to a deep red. The infiltration is slight, 
and the patch is situated superficially. Itching is commonly in- 
conspicuous among the symptoms. 

The fully formed disks vary in long diameter from the width of 
a finger-nail to three or four centimetres. The oval contour is that 
more often recognized as characteristic of a well-developed lesion, the 
long axis of the disk usually corresponding with the lines of cleavage, 
and the terminal extremities of the oval slightly frayed by the irregu- 
larity with which the fine branny scales are there disposed. A tawny, 
salmon-shade La highly characteristic of the disease, the patch slightly 
enlarging by peripheral extension, and Leaving a relatively clear cen- 
tre. The Bcales have often ;i silvery grayish color. The eruption 
may be fairly well generalized, but the face and other exposed 
l>aii- of tlic body usually escape, though the scalp may be involved. 
In the Latter evenl the hairs arc unaffected. The evolution of the 
eruption may 1m- by successive development of tin- eruptive elements 
at interval- of "lie to ten weeks, the first being generally tbe mosl pro- 
fuse and brilliant. 

The variations exhibited by the exanthem in this affection are 
distinct, but are scarcely ever sufficient to ma<k the characteristic 

appearance of the "\al or circular plaques over tbe neck, the arm-, 
the abdomen, or the extremities; sometimes first appearing over the 

latter and extending thence to the trunk. At times a retiform ex- 
pression is given t«» the picture by coalescence of the patches. There 
may be moderate itching with nocturnal exacerbation, Inn tbe usual 
type of the disease is mild. The affection run- it- course ordinarily 
in from ten days to six week-, but may hist several months if new 
Lesions continue to appear. Recurrences are rare. 

Etiology. — The causes of this disease are obscure. It is without 
question more common in the spring and in the autumn than at 
other seasons. Bazin believed it occurred chiefly in lymphatic and 
scrofulous patients. Most patients are young (fifteen to forty years 
of age), many are of the female sex, have light hair and delicate 
skins, and have been enfeebled by physical fatigue or by overtaxa- 
tion in school. Profuse perspiration has been assigned as a cause 
by Horand. Though no true epidemics are reported, and positive 
evidences of contagion are wanting, it occasionally happens that the 
disease is so unusually prevalent during a few weeks in a given 
locality as to suggest an epidemic; there are also instances in wTiich 
two members of the same family were affected. (Crocker, Zeisler, 
Fordyce, G. II. Fox.) It is possible that the disorder is feebly in- 
fectious and allied to the exanthemata. Szoaboky, in 50 per cent. 



PITYRIASIS BO SEA. 301 

of 119 cases of this disease, recognized that there was but slight 
febrile movement before development of the eruption. Of the entire 
number of patients one only had a return of symptoms. The author, 
after microscopic examination failed to recognize a parasitic etiology 
for the disease; but in 66 per cent, of cases, discovered that there 
were functional troubles of different character connected with the 
nervous system (sweating, trembling, pallor and redness, headaches, 
and exaggerated reflexes). 

Pathology. — The histopathology of the disease has been studied by 
Darier, Unna, Hollmann, and Sabouraud. The changes begin ap- 
parently in the papillary body and the subpapillary layer of the cutis 
and include a dilatation of the vessels, perivascular cell-infiltration, 
and oedema. As the disorder progresses these changes are more 
marked, especially the perivascular cell-infiltrate. The rete shows 
decided intracellular oedema and proliferation of the prickle-cells, es- 
pecially in the interpapillary portions. As the disease approaches 
its acme, minute vesicles, not visible on macroscopic examination, 
form beneath the horny layer, which later is exfoliated. Sabouraud 
states that these vesicles are found in the outer layers of the epidermis 
much as the "dry abscesses" described by Munro are formed in 
psoriasis. The absence of polynuclears (phagocytes) in the vesicles 
leads him to believe the disease is not parasitic, but a vesicular 
erythema of toxic origin. Oppenheim and Mewborn, however, be- 
lieve that there are evidences of a microbic origin to the disease. 
The former recognized double contoured organisms suggesting an 
oidium, which in one instance appeared to transmit the disease from 
cultures ; while the latter found a mould-fungus with grape-like clus- 
ter of spores. 

Diagnosis. — When fully developed and presenting characteristic 
lesions with a yellowish-brown centre and a pale frayed border cov- 
ered with fine scales, the diagnosis is simple, especially if a number 
of the oval patches show the usual arrangement with the long axes 
in the lines of cleavage. When the lesions are numerous but less 
perfectly developed, and are of the smaller, maculo-papular and more 
inflammatory type, the disease may resemble a maculo-papular syph- 
ilide so closely as to defy even the expert. In the absence of all other 
evidences of syphilis, delay of a few days usually will permit the 
development of either the typical oval lesions of pityriasis rosea, or 
of other signs of syphilis. In syphilis, the elementary macules are 
uniformly smaller, much less disposed to scale. Ordinarily the 
lesions of pityriasis rosea are less infiltrated, are of a brighter but 
paler tint, and are more rapid in evolution than those of syphilis. 
The congestion of the fauces in the former is of a bright-red color 
and diffuse, while that of syphilis is dull red and circumscribed. 

Dermatitis seborrheica. — In this disease the slow development of 
the lesions, their distribution over the scalp, sternum, and between 
the scapulae rather than on the trunk along the lines of cleavage, the 
coarser and more abundant scales, the fine papules on the one hand, 



302 HYPEREMIAS AND INFLAMMATIONS. 

or large areas on the other, and the absence of atypical oval lesions 
of pityriasis rosea, will establish the diagnosis. Cases there are in 
which the differential diagnosis is exceedingly difficult or almost im- 
possible, and which suggest an intermediate stage between the two 
disorders. 1 

Psoriasis, — In psoriasis the patches are infiltrated, elevated, and 
more sharply defined. The abundant, imbricated, and silvery-white 
scales, the bleeding points beneath, and the distribution of the lesions 
are points of value in the diagnosis. 

Ringworm. — In ringworm of the glabrous skin the lesions are 
rarely so numerous or so symmetrically distributed. The areas are 
more definitely circular, more circumscribed, and often display min- 
ute vesicles at the periphery. The areas showing clearing centres are 
larger than those of pityriasis rosea. Finally, the fungus can be 
demonstrated in the scales. 

Treatment. Pityriasis rosea, ;is a rule, is a self-limited disease 
in which the duration and career vary greatly in different cases. 
Consequently it is difficult to judge of the value of treatment in a 
given case. Systemic treatmenl should be varied to inert the indica- 
tions in each instance. The febrile and throat symptoms, it present, 
should receive proper attention. In many casea do internal treatmenl 
is required. Crocker believe- the course of the disease i- shortened 
by giving Balicin in 15 grain (1.) doses three times a day. The diet 
should be light and simple. Tonics are often indicated. Locally, mild 
sulphur or other antiseptic ointments appear to shorten the duration 
of the disease in many instances. A convenient and simple treatment 
which we have employed with apparently good results in many cases 
is as follows: The patient takes a bath at night before retiring, and 
after drying the skin applies to the areas a weak vinegar or dilute 
solution of acetic acid, and before this dries follows with a 10-15 per 
cent, solution of sodium hyposulphite. Tn a few moments, after the 
surface is dry, a simple dusting-powder may be applied. In the 
few instances in which itching or burning is annoying, the under- 
clothing should be of silk or cotton, and the surface of the body should 
be kept constantly covered with some adherent powder, like zinc -t< ur- 
ate. Rarely is it necessary to use soothing, mildly antipyretic lotions 
or ointments, such as are recommended for the early stages of eczema. 
In unusually extensive cases in which itching is a pronounced feature, 
brief exposures to rc-rays are followed promptly by cessation of sub- 
jective sensations and by rapid involution of the lesions. 

Eecent Literature. 

Holhnann: Archiv, 1900, li., p. 229. 

Sabouraud: Abstr. in J. C. D., 1903, xxi., p. 55. 

TJnna: Histopathology, 1896, p. 267. 

Ora and Mosca: Comment Clin. d. Mai. Cut., 1894. 

Darier {cf. Moingeord, 1. c). 

Szoaboky: Monatshefte, 1907, xlii., p. 495. 

1 Cf. Besnier, Annales, 1889, s. ii., x. 3 p. 108. 



PARAKERATOSIS VARIEGATA. 303 

Zeisler: J. C. D., 1893, p. 694. 

Fordyce: J. C. D., 1893, p. 497. 

Oppenheim : Verhandlung. der 79 deutsch Naturf orscher und Aertze, Sept., 1907. 

Newborn: J. C. D., 1906, xxiv., pp. 431-432. 

Towle, H. P. : J. C. D., 1904, xxii., pp. 177-182. 

PARAPSORIASIS. 1 

(Lichen Variegatus (Crocker), Resistant Maculo-papular 
Scaey Erythrodermas (Fox and MacLeod 2 ).) 

Parapsoriasis is a generic term introduced by Brocq to designate 
certain eruptions of the skin which though differing one from another 
in appearance present certain features in common. It is now univer- 
sally accepted as the best name for these eruptions. Many clinicians 
are satisfied to designate a given case by this term without attempt 
to specify which particular dermatosis of the division the case 
represents. Whether the affections of this division are different man- 
ifestations of a single disease or several closely allied diseases is an 
unsettled question. Some of the cases which have been recognized as 
belonging to this division by all authorities have been assigned to one 
dermatosis of the division by one, and to another dermatosis of the 
division by another observer. The case reported by Anthony 3 is par- 
ticularly valuable in this connection because it was seen by so many 
dermatologists both in America and England. The occurrence of 
mixed forms increases the difficulty of studying these eruptions 
(Csillag 4 ). The clinical features which the dermatoses of this 
division present in common are : the superficial character of the erup- 
tion ; the mild degree or entire absence of infiltration of the skin and 
of itching ; and the failure of tendency to recovery. 

PARAKERATOSIS VARIEGATA.5 

(Parapsoriasis Lichenoide. ) 

This was the first dermatosis of the parapsoriasis group to be 
recognized as an independent affection. The first case was described 
by Unna and Santi and Pollitzer in 1890. It had previously been 
designated superficial lichen planus. The eruption usually occurs 
in the third or fourth decade of life; it affects robust individuals. 
It is universally distributed over the trunk and most of the extremi- 
ties. It is retiform in character, almost as if the patient were cov- 
ered with a net ; more closely studied, the net-work is seen to be made 
up of red streaks and patches, varying in shade in different parts of 
the body (P. variegata) ; the eruption is sharply defined, very super- 
ficial and covered with a fine lamellous scale. The meshes of the net 
are occupied by irregular, slightly sunken areas of healthy skin. 

1 Annales, 1902, s. iv., iii., p. 433. 

2 J. C. D., 1901, p.-424 (histology). 
8 J. C. D., 1906, p. 455 (literature). 
*Archiv, Ixxvi., p. 3 (mixed form). 
5 Monatshefte, 1890, i., p. 444. 



304 HYPEREMIAS AND INFLAMMATIONS. 

The premycotic eruption of mycosis fungoides may present the 
clinical picture here depicted. Cases which have been accepted as 
probable cases of parakeratosis variegata and subsequently by the 
development of infiltration and microscopical examination have been 
shown to be cases of premycotic mycosis fungoides are reported by 
Jamieson, 1 Hudelot, Gaston, 2 Sherwell, and also the first case of 
TJnna. Some students of the subject will not accept as examples of 
the disease cases which do do1 present the typical retiform appearance. 

The cases which presented the plaque arrangement are: that re- 
ferred to by the writer and accepted by Unna, that of Meneau, 
and that of Anthony. 

DERMATITIS PSORIASIFORM^ NODULARIS.- 

(Pityriasis Lichenoides Chronica. Ger., Eioenabtiqes Psori- 
asiform^ r.\i> Lichenoides Exanthem; Fr., Parapsoriasis 

I \ OOUTTES.) 

This form of parapsoriasis was firsl described by Jadassohn in 
1894. The eruption is \>-ry superficial, consisting of pin-head to pea- 
sized papules, round, or oval in form, of an intense clear rc<\ color; 
the Larger are paler, they are well denned, the -mailer arc -lightly 
pointed, while the larger arc flal with an occasional central depres- 
sion; they arc Bomewhal firm, some are follicular. -<■■,[}(■- are nod 
always visible but when scratched, may be removed from any of 
the lesi<m>. The scratched lesion is v<\ and Meed- bu1 Little; there 
are no bleeding points as in psoriasis. The scale when removed is 
thicker in the middle than on the periphery. New papules or nodules 
appear here and there so that the eruption gradually increases. In 
the beginning there is an areola of redness. Pick, 4 Civatte ( Broco/s 
( 'linic i .M ilian and Pinard" have reported cases of this disorder which 
on microscopical examination were found to be tuberculides. Civatte 
surmise.- that they an- all of this nature. 



ERYTHRODERMA PITYRIASIQUE EN PLAQUES DISSEMINEES. 
(Parapsoriasis en Plaques. I 

Brocq, White and Little have reported cases of this affection. 

White gives the following description of the appearance of the erup- 
I ion in one of his cases. " The front and lateral surfaces of the 
trunk were thickly occupied by irregular circular or oval areas vary- 
ing from ^ to 1^ inches in longest diameter. They were generally 

JJ. C. D., 1901, p. 441. 

; Annates, 1904, s. iv., v., p. 1090. 

3 Archiv, lxv., p. 61 (literature). 

1 Archiv. txix.. p. 411. 

5 Annates, 1907, s. iv.. ix., p. 477. 

« J. C. D., 1900, p. 536. 



PLATE VII 

FIG. 1 




'•■ 




Erythrodermie Pityriasique. (C. J. White.) 



Fig. 1. (Section.) Low power. Represents the section as a whole, with the most gravely affected regions 
of the corium and of the epidermis in the centre of the photograph. The great atrophy of the epidermis and 
the disorganized condition of the corium are well shown. On each side of the photograph the corium is begin- 
ning to appear more normal, and on the left hand the various normal deeper structures are present. Hema- 
toxylin-eosin. 

Fig. 2. (Section.) High power. Represents the most severely affected area of the epidermis. The rather 
increased stratum corneum and the marked changes of the other layers are clearly seen. Hematoxylin-eosin. 



DERMATITIS EXFOLIATIVA. 305 

discrete, but here and there formed larger patches by confluence. 
They were all habitually of a light brown color, but might become 
somewhat redder on exposure to cold. The brown tint disappeared 
partially on long and firm pressure. They were mostly free from 
visible scales (the patient bathed frequently) and presented neither 
elevation nor infiltration. They provoked no subjective sensations. 
On the back, patches were less abundant and slightly redder." 

Rille and Biecke 1 classify these cases as a variety of idiopathic 
atrophy of the skin. The fact that the elastic fibres are not affected 
in this disease while they disappear in ideopathic atrophy, excludes 
this possibility. 



XANTHOERYTHRODERMIA PERSTANS (CROCKER). 2 

In this form of eruption, the lesions affect the covered parts of 
the body. The disease develops symmetrically, very gradually, and at 
first in small numbers of patches but as the older patches never dis- 
appear spontaneously, while fresh disks are in continual evolution at 
short or long intervals, large areas are involved. The patches may 
remain discrete or coalesce. The disease is apt to first appear on the 
thighs and legs. A simple patch is from one inch to three inches in 
its longest diameter and oval in shape. The borders are not well de- 
fined but there is no difficulty in discerning the morbid from the 
healthy skin. There is no elevation of the lesion. There is a slight 
degree of infiltration in some older patches while in those more recent 
and smaller it is imperceptible ; occasionally they look like mere 
stains. The color is either pale pink or yellowish; the surface is 
smooth in the trunk but is often slightly rough on the arms and 
thighs ; below the knees the surface may be distinctly rough or even 
exhibit branny scales. The eruption may disappear spontaneously. 

Histology. — A comparative study of the histology of these erup- 
tions has not been made; it is not known in what respects if any 
they differ. The features they present in common are epidermal 
atrophy. The epidermis is narrowed to simply a few rows of cells. 
There is an inflammatory exudate surrounding the dermal vessels, 
with no change in the dermal bundles or elastic fibres. 



DERMATITIS EXFOLIATIVA. 

(General, Exfoliative Dermatitis. Fr., Erythroderma ex- 

FOLIANTE (BESNIER), DeRMATITE EXFOLIATRICE. ) 

Exfoliative dermatitis is a disorder in which over considerable 
portions or the entire surface of the body the skin is reddened and 
covered with lamellated scales which are exfoliated freely from the 

1 Archiv, Ixxxiii., p. 51. 
2 B. J. D., 1905, p. 119. 

20 



306 HYPEREMIAS AND INFLAMMATIONS. 

surface; the disease may be accompanied by itching or burning sensa- 
tions, and by febrile and other signs of systemic disturbance ; and 
may pursue an acute or more commonly a chronic course. 

Some confusion, both as to the names of diseases and as to the 
diseases themselves, has existed in connection with the subject of all 
generalized exfoliative cutaneous disorders. More investigation is 
needed before definite limits can be established for several of the 
dermatoses of this class. By some, the term dermatitis exfolia- 
tiva is held to be Bynonymous with pityriasis rubra. In these 
pages the term pityriasis rubra is restricted to the disease first de- 
scribed under this title by Hebra, and the name Dermatitis exfolia- 
tiva, is employed us a generic designation of the entire group <>f der- 
matoses, acute or sub-acute in type, accompanied by generalized and 
extensive exfoliation of scales from the cutaneous surface. 

Etiology.— -Male somewhat outnumber female subjects <»f the 
disease, the most being between twenty and forty years of age. 

The several toxaemias, gout, rheumatism, tuberculosis, chronic 
alcoholism, the general causes of anaemia, asthenia, and cachexia 
have all been cited as etiological factors in the several forms of 
exfoliative dermatitis, ami in cases each of the causes named has 
been effective. Central and peripheral neuroses are ;it times at 
fault, The disease is in many cases unquestionably profoundly 
affected by climatic influences often firs! appearing in the autumn of 
the year. Medicament.. u< ingesta and injects (quinine, arsenic, 
antipyrine, antitoxin sera) may produce conditions of the same 

character. 

Pathology. — The pathological findings in mosl cases have been 

typical of the usual pr sses of inflammation, including thickening 

of the horny layer, early accentuation and eventual disappearance 
of the granular layer, oedema of the rete, a plastic felting together 
of the upper layers of the corium with loosening of those lying deeper, 
dilated blood-vessels, absence of mast-cells, and everywhere cell-infil- 
tration. 

Diagnosis. — The disease may be differentiated from scarlatina by 
the absence of fever, the condition of the tongue, and the fact, when 
such can be substantiated, of previous attacks. Psoriasis, lichen 
ruber, and dermatitis Beborrhoi'ca, may all be recognized by a study 
of their distinctive features, remembering thai it i- exceedingly 
rare that any one of the disorders mentioned becomes absolutely 
generalized: that in most the itching is far more severe than in ex- 
foliating dermatitis: and that desquamation in fine scale-. Bero-pustu- 
lar oozing with crusting, and localization in certain regions of the 
body, each different from the other, are all of diagnostic value. At 
times the pre-fungoid stage of mycosis fungoides may suggest some 
of the early manifestations of Dermatitis exfoliativa ; and the possi- 
bility of such an issue, even though not at first demonstrable, should 
not be forgotten. 

The true character of the disease cannot be determined always 



DERMATITIS EXFOLIATIVA. 307 

at the time of its onset. Other inflammatory and scaling conditions 
of the skin must be excluded by the absence of the features character- 
istic of each. In more advanced stages the history of the disorder, 
as well as the absence of the characteristic features of other diseases 
with which it might be confused, will be of value in diagnosis. 

From pemphigus foliaceus, Dermatitis exfoliativa is distinguished 
by the absence of bullae and by the absence in most cases of grave sys- 
temic disturbance. 

The disorder may rarely closely simulate pityriasis rubra of 
Hebra, but the history of steady progression without remissions, the 
universally reddened scaling epidermis without infiltration, the ulti- 
mate atrophy of the skin, the not infrequent ulceration and gangrene, 
and finally the serious systemic conditions — all classical features in 
pityriasis rubra — rarely are found in such combination in Dermatitis 
exfoliativa. 

Treatment. — As at least some cases are due to a toxaemia, the 
general condition of the patient should be investigated thoroughly, 
and treatment instituted to meet indications. Mook 1 and Engman 
of St. Louis report favorable results after treatment of Dermatitis 
exfoliativa with quinine in large doses. The tolerance in all cases 
was remarkable. The amount taken in twelve hours was increased 
to 80 and 85 grains, the dosage being reduced when there was 
tinnitus aurium. Arsenic is occasionally of value, but as a rule fails, 
as do other so-called specific remedies, to relieve the condition. Sod- 
ium cacodylate falls in the same category. Any medicament which 
induces profuse sweating, such as aspirin, jaborandi, and pilocarpin, 
may give relief, and in some instances their use has been followed 
by recovery. Locally, applications should be employed to keep the 
skin soft and to relieve itching or other sensations which may be 
present. For this, Hebra's ointment, 1 part to 4 of vaselin with 
from 5 to 10 grains (0.33-0.66) of salicylic acid to the ounce (30.) 
of the whole, is usually grateful to the skin. An ointment often em- 
ployed with great advantage over the entire cutaneous surface is: 

]J Sulphur, precipit., \ 
Acid, salicylic, J 
Bals. Peru., 
Ungt. petrolat., ") 
Ungt. ag. ros., J 

Other simple ointments and oils with or without the addition of small 
amounts of salicylic acid, carbolic acid, ichthyol, tar, or other reme- 
dies may be of value. As a rule, mild preparations are more ser- 
viceable than the stronger remedies. One of the combinations of 
lime-water, olive oil, and zinc-oxide, described in the treatment of 
eczema, is occasionally of service. Emollient, starch, and hot baths 
are generally comfortable to the skin. 

Prognosis. — In the majority of instances the patient eventually 

1 Mook, J. C. D., Sept., 1908, p. 408. 



aa gr. ijss; 


[166 


m. x; 


|66 


aa ^ss; 


15 1 M. 



308 HYPEREMIAS AND INFLAMMATIONS. 

recovers, though convalescence often is protracted and delayed by- 
frequent recurrences. A small proportion of cases progress to the 
formation of universal or exfoliative dermatitis from which the 
patient rarely recovers. In grave and protracted cases the general 
health of the patient suffers and a fatal result may be expected. 

PITYRIASIS RUBRA (HEBRA TYPE). 
(Gr., trirvpav, bran.) 

( I )i i:\ia titis Exfoliativa. Ger., Rotiikleie; Fr., Pityriasis 

KFBRA AIGU.) 

Pityriasis rubra is ;i rare, chronic, and usually grave inflamma- 
tory cutaneous disease, involving as a rule the entire Burface of the 
body, in which the skin usually without infiltration becomes deeply 
reddened and exfoliates lamellae of scales in large quantities. I here 
is commonly no subjective sensation save that of chilliness; and the 
later symptoms and sequelae of the affection are: Bhedding of the 
hairs, adenopathy, pigmentation, atrophy, and, as a consequence of 
pressure and friction-effects, ulceration. The cutaneous manifesta- 
tions are probably bul symptoms of Bystemic disease which in the 
majority of cases terminates fatally. 

The disease here described is the Pityriasis rubra of Bebra, which 
Bhould qoI be confused with other forms of dermatitis exfoliativa. 

Symptoms. This disease i« characterized by a superficial hyper- 
eemia and inflammation of the -kin. declared in patches or by a dif- 
fuse redness of a vivid or lurid tint, and by an abundance of -mull 
or large, lamellated, bran-like scales, which are continuously exfoliated 
from the epidermis throughout the course of the malady. Patients 
rarely present themselves for observation until a considerable portion 
of the body-surface is involved; but Kaposi states that in two pa- 
tient- observed by him the disease was first noticed in tin- neighbor- 
hood of the articulations. There is no vesiculation, pustulation, 
moisture, or crusting. The palmar and plantar surfaces are usually 
less distinctly reddened than the face and the extremities, having at 
times even a pallid hue, but they are always covered with a scaling 
epidermis. 

Under pressure with the finger the redness subsides <>r assumes a 
yellowish shade, while, as a rule, when the integument is gathered 
up between the finger and thumb, no infiltration can be recognized. 
Exceptions, however, have been noticed by several observers. 1 The 
temperature of the skin is slightly increased. The exfoliation, as the 
diseases progresses, is one of its most striking eharaeteristics, the 
scales accumulating in large quantities in the clothing of the patient, 
who is engaged, as a Trench writer has it, in the labor of stripping 
himself involuntarily of his epidermis. 

1 We have observed several such cases. Cf. ' ' Pityriasis Bubra, ' ' Chicago Med. 
Jour, and Exam., Feb., 1881. 



PITYRIASIS EUBBA. 309 

The disease persists for months or for years, being always more 
severe in expression as it advances, the papery scales being shed more 
abundantly and in larger flakes, leaving a smooth, shining occasion- 
ally purplish, or even cyanotic skin. In the patients observed by 
Jamieson, 1 the skin was so dark hued as to suggest the color of a 
mulatto. Gradually the patient becomes conscious of an increasing 
sense of chilliness, as if deprived of sufficient body-covering. The 
itching may be absent, be moderate, or be severe. There may be in- 
stead sensations of stiffness, burning, and tingling. Later the integu- 
ment seems to retract, as if it were insufficient to encompass the body, 
and becomes subject to fissure from extension and contact, while the 
lower extremities may be cedematous. This retraction may be so 
marked that ectropion of the eyelids may ensue, the fingers may re- 
main semiflexed, and wide opening of the mouth may become diffi- 
cult. The skin over bony prominences becomes thin and stretched, 
and often fissured, or becomes the seat of superficial ulcers or of gan- 
grene. Thinning of the skin of the soles of the feet may render 
walking painful or impossible. The hairs and the nails lose their 
lustre and become friable, and the hairs often fall, though the nails 
may escape. 

The influence of this epidermal exfoliation, involving, as it does, 
finally, every portion of the body-surface, does not fail toward the 
end to be felt by the vital forces. Alternating chills and febrile 
processes, pneumonia of a low grade, colliquative diarrhoea, tubercu- 
losis, subcutaneous abscesses, bedsores, and even gangrene of the skin 
may close the scene. 

Hebra and Kaposi together had under observation twenty-one 
patients affected with pityriasis rubra, who, with a single exception, 
died from its effects. It will thus be seen that the disease is rare. 
A few cases have been reported by British authors. Among Ameri- 
cans, Duhring, George H. Fox, of New York, and the writer, have 
published reports of cases. We have had under observation in all 
more than a score of .typical instances of the affection. The disease 
is one of early or of middle life, and affects preeminently the male sex. 

The progress of the disease is slow, lasting for years, though in a 
few instances it has proved rapidly fatal. The time required for 
extension to the entire surface of the body varies from a few days to 
two years or more, but averages from three to eight months. From 
the first the tendency of the disease is to progress slowly to a universal 
atrophy of the skin. Involution of areas, or periods of improvement 
of the cutaneous symptoms, are very unusual. There are no red 
points visible as in other forms of scarlatinoid-shaded eruption, and 
the color when the palms and soles are involved only appears after 
the thick epidermis of these regions has been shed. Sweat may 
or may not be secreted in the course of the disease. The tongue 
is bright red in the early stages ; later it is covered with a brownish 
crust; it occasionally undergoes exfoliation. There may be a secre- 
1 Edinburgh Med. Jour., 1880, xxv., p. 879. 



310 STPER^MIAS AND INFLAMMATIONS. 

tion from the skin which at times stains the linen. Rhagades may 
form, especially in the palmar and plantar regions. While in the 
instances of this disorder first described in Vienna there was no 
infiltration of the skin, this change has been observed in other typical 
instances, but usually not deeply implicating the corium. The nails 
may be separated, tilted up from the nail-folds, softened, thinned, 
fissured, " worm-eaten," or otherwise altered. The chief systemic 
symptoms recorded are: languor, chilliness, and even severe rigors al- 
ternating with febrile temperatures of recurrent type, albuminuria, 
diarrhoea, pulmonary oedema, icterus, interstitial pneumonia, bronchi- 
tis, and rheumatism. 

Etiology. — The causes of the disease are unknown. It is more 
common in men than in women, and in adults rather than in children. 
The cutaneous phenomena are due in each case to some constitutional 
disorder which in the early stages frequently presents no other symp- 
toms than those manifested on the skin, the patient being apparently 
in good health. Visceral troubles are recognized chiefly at a late 
period of the malady, when it would appear that the cutaneous mia 
chief is sufficiently extensive to induce them. The wide range of 
these disorders suggests thai the cutaneous disease may result from a 
number of visceral maladies. 

Pathology. — Montgomery and Bassoe found that the necropsy in 
their case pointed to a primary in fiction of the skin followed by a sec- 
ondary general marasmus. The rete-pegs were elongated; the granu- 
lar layer of the skin undemonstrable; the papillary and upper reticu- 
lar layer infiltrated with cells apparently of connective-tissue origin. 
The deeper cutis was not involved. There was peri-vascular infiltra- 
tion of numerous enlarged vessels, having a thickened intima, and 
blocked with blood-cells. The connective tissue below the zone of 
infiltration was both hypertrophied and sclerotic. There were numer- 
ous pigment-cells throughout the cutis, resembling mast-cells. Tschle- 
now states that the primary changes occur in the epidermis, pro- 
ducing secondary inflammation in the cutis which ultimately leads to 
complete atrophy of the skin. 

Both Hebra and Fleischmann discovered coincident pulmonary, 
intestinal, or cerebral tuberculosis. Kaposi established an atheroma- 
tous condition of the arteries. Myelitis was discovered post-mortem 
in one case by Jamieson, who has been followed by others in the recog- 
nition of central and peripheral neurotic alterations. Kopytowski 
and "Wielowicyski describe cocci which they think are factors in pro- 
ducing the disease. 

Jadassohn's admirable investigation of the entire subject led him 
to the conclusion, shared by Doutrelepont, that a large proportion 
of all cases of the disease were tuberculous in origin. Montgomery 
and Bassoe state that the causative relation between the two is not 
at all clear. 

Bowen's patient 1 was said by Dr. Charles J.White to have suffered 

1 Discussion of Montgomery and Bassoe 's paper, loc. cit. 



PITYRIASIS RUBRA. 311 

from a small abscess in the lung which may have been tubercular. 

A case of pityriasis rubra, of the Hebra type, reported by Muller 1 
accompanied by tuberculosis of the lymphatic glands was more fully 
described after death of the subject by Fabry 2 who concludes after 
recognition of the existing tuberculosis that the contention of Jadas- 
sohn and Doutrelepont respecting the tuberculous character of a large 
proportion of similar cases, requires further confirmation. Halle, 
moreover, is doubtful as to the existence of tuberculosis in a similar 
case reported by him. 3 The researches of Hans Hebra demonstrated 
in two cases that in the earlier period of the disease there is an in- 
filtration of the integument moderate in degree, succeeded at a later 
period by cutaneous atrophy, in which the rete and papillae of the 
corium disappear. The connective-tissue elements undergo sclerosis ; 
and the glands and the follicles of the skin are destroyed. Pigmenta- 
tion is abundant. Petrini and Jadassohn reported inflammatory 
infiltration of the papillary and subpapillary layers of the corium, a 
proliferation of connective-tissue cells, and secondary changes in the 
epidermis. 

Diagnosis. — Many cases reported as instances of pityriasis rubra 
are not really such. The misinterpreted symptoms are often those of 
an unusually extensive psoriasis or a chronic squamous eczema, 
which commonly terminates favorably in the course of proper treat- 
ment. 

Psoriasis rarely extends over the entire surface of the body,' but 
at times it is thus generalized. In these exceptional forms a long 
history of the occurrence of typical psoriatic patches may usually be 
obtained, while the bleeding surface beneath the scales and the char- 
acter of the latter will point to the true nature of the disease. Psori- 
asis occurs in healthy, pityriasis rubra in cachectic, constitutions. 
Extensive erythematous or squamous eczema, apart from all other 
symptoms, can be recognized at once by the excessive distress oc- 
casioned by the eruption. The patient lies in bed nursing his or her 
tender limbs, back, or belly. In the early stages of pityriasis rubra 
the patient may rise, dress, and move about with an expression, not 
of pain, but of listless apathy. His scales are not scanty and ad- 
herent, but are abundant and exfoliate freely. There is, from first to 
last, no history of moisture. In every generalized eczema, at one 
point or another, there always will be a surface which weeps. In 
its early periods pityriasis rubra can be distinguished from pemphi- 
gus foliaceus by the absence of bullae and of the intolerable stench 
which is often emitted by the sufferer. When, however, there is 
present merely a generalized exfoliative dermatitis the two disorders 
may well-nigh be indistinguishable. 

Treatment. — Arsenic administered internally seems powerless in 
pityriasis rubra. Cases are on record of fatal results after the ex- 

1 Archiv, Ixxxxvii., p. 255. 

2 Ibid., 1908, xci., p. 85. 

8 Ibid., 1907, lxxxviii., p. 247. 



312 HYPEREMIAS AND INFLAMMATIONS. 

hibition of this drug in prodigious quantities for long periods of 
time. Tar externally promises no better result. Kaposi reports a 
single patient relieved by the use internally of carbolic acid. Thy- 
roid extract may be tried in chronic cases. 

We have had the opportunity of verifying the improvement 
which may result from the administration of large doses of quinine, 
— as recommended by Engman, — in three cases of pityriasis rubra 
in our care. The dose was progressively increased from the medicinal 
quantities usually given, to fifty, sixty, and even ninety grains in the 
day, extreme care being taken of the heart's action and the audition. 
The tolerance of the drug was in all cases distinct, and the improve- 
ment marked. 

A roborant treatment, including the employment of cod-liver oil, 
iron, or quinine, is generally indicated, with externally the simplest 
bland unguents, such as vaselin, lanolin, or diachylon ointment. 
They should be employed, not merely to soothe, but also to protect 
the skin. Continuous baths may be of service in making the patient 
comfortable. The clothing should be ample and unirritating, and the 
diet selected with a view to supporting the strength. 

Prognosis. — The majority of all the cases of the pure Hebra type 
have terminated fatally. 

Recent Literature. 

Tommasoli: Beitrag zur Histologic der Pityriasis rubra, Monatshefte, 1889, ix., 
p. 246. 

Doutrelepont : Beitl&g zur Pityriasis rubra (Hebra), Archiv, WOO, li., p. 109. 

Sellei: Die Pityriasis rubra (Hebra), Ed., 1901, Iv. 

Tschlenoff: Ein Beitrag zur Kenntnis der Pityriasis rubra, Td., 1903, lxiv., 
p. 21. 

Peter: Uber Pityriasis rubra and <li'' Beziehungen zwischen Bautkrankheiten 
und Pseudoleukauiir. Derm. Zeitschr., 1893- 1894. 

Montgomery and Bassoe: Pityriasis rubra of Hebra type, .1. « . It., L906, xxiv., 
p. 298. 

Brocq: Trait, in. nt dee maladies de la peau, Paris, 1890. 

Jadassohn: Obex .li>' pityriasis rubra (Hebra) und ihre Beziehungen zur 
TuberkuL.se. Arch., 1891, x x i i"i . , p. 961; 1892, xxiv., pp. 85, 271, 462. 

Colin: Uber pityriasis rubra, Dissert. Wurzburg, 1884. 

Bruusgaar.l: Beitrag zu den tul.rrkul.iscn Hauteruptionen. Erythrodermia ex- 
foliativa universalis tuberculosa. Archiv, 1903, lxvii., p. 

Kopitowski-W'ielowicyski: Beitrag zur Klinik und i>athologischen Anatomie 
der Pityriasis rubra Hebra?. Archiv, 1901, Ivii.. p. 33. Bibliography to date 

Kanitz: Beitrag zur Klinik. Histologic und Pathogenese der Pityriasis rubra 
(Hebra), Id., 1906, lxxxi., p. 859. 

Gilchrist: Pityriasis rubra, Monatshefte, 1907, xliv., p. 139. British Med. 
Assn. Toronto, August, 1906. 

Halle: Uber einen Fall von Pityriasis rubra (Hebra), Archiv, 1907, lxxxviii., 
pp. 247-266. 

Bartheleme: Zwei Falle von Pityriasis rubra Hebra?, Inaug.-Dissert. Strassburg, 
1902; Monatshefte, 1905, xli., p. 389. 

Miiller: Pityriasis rubra, Hebra, mit Lymphdriisentuberkulose, Archiv, 1907, 
lxxxvii., pp. 255-266; Monatshefte, 1908, xlvi., p. 31. 

Fabry: Ein fall von Pityriasis rubra Hebra? mit Lymphdriisentuberkulose. 
Nachtrag zu der Arbeit von O. Miiller, Archiv, 1908, xci, p. 85. 

Arning: Fall von Pityriasis rubra Hebra?, Demonstrationsabende im Alten 
Allgemeinen Krankenhause St. Georg, Hamburg, Archiv, 1907, lxxxvii., p. 463. 



DEBMATITIS EXFOLIATIVA NEONATORUM. 313 

DERMATITIS EXFOLIATIVA NEONATORUM. 

(Keratolysis Neonatorum; Bitter's Disease.) 

Under this title Ritter v. Rittershain and others have described 
a rare exfoliating disease of the skin in nursing infants from six days 
to five weeks old, occurring most commonly in foundling asylums. 
The disorder begins usually as a reddened, exfoliating patch, most 
frequently on the lower part of the face, though it may appear first on 
any part of the body, and rapidly spreads until the entire surface is 
reddened and exfoliating. The surface beneath the scales is red, 
usually dry, and often excoriated. Occasionally the surface is moist, 
and in some instances vesicles and bullae appear in areas — a fact 
which led Eichter and others to class the disease with pemphigus 
neonatorum. The angles of the mouth and the mucous outlets of the 
body frequently show fissures and are covered with crusts. Often 
the mucous membranes of the mouth, nose, and conjunctiva are in- 
volved. The duration varies. In most cases there is complete in- 
volution in from seven to ten days with few or no constitutional 
symptoms. Severe cases may last a month or longer with disturbance 
of the digestion and assimilation, and production often of marasmus. 
Pneumonia is of frequent occurrence. As a result of secondary 
infection, furuncles and abscesses are common; gangrene and sepsis 
may follow. When healing occurs, it is accomplished as a simple 
and gradual diminution of the erythema and cessation of the scaling. 
Recurrences are not uncommon. 

Etiology and Pathology. — Observers are not agreed respecting 
the cause and nature of Dermatitis exfoliativa neonatorum and its 
relations with pemphigus acutus neonatorum. Ritter, Winternitz, 
Luithlen, and Bender hold that these two disorders differ in respect to 
the fact that in the first named disease, the prickle-cells of the rete 
increase, which does not occur at least to the same extent in pemphi- 
gus neonatorum. In two cases studied by Hedinger, the staphylococ- 
cus pyogenes aureus was recognized on bacteriological examination; 
and the author concludes that dermatitis exfoliativa of the new-born 
is merely a malignant variety of the pemphigus of infants. Ritter 1 
believed in its septic origin. Kaposi considered it an exaggeration of 
the normal exfoliation of the newborn. To the bacteria found in 
the lesions or in the blood no definite etiological relation has been es- 
tablished. Histological examinations (Winternitz, Luithlen) show 
merely a superficial inflammation, often with free exudation, and 
excessive exfoliation of the epidermis. 

1 Eitter, Centralzeitg. f . Kinderheilk., 1878, Btf. ii., and Vierteljahr., 1879, vi., p. 
129; Elliott, Amer. Jour. Med. Sci., 1888, xcv. (with survey of literature); Luithlen, 
Archiv, 1899, xlvii., p. 323; and Mracek's Handbuch, Bd. i., p. 757 (full bibliog- 
raphy) ; Hedinger, Arehiv, 1906, 349 (with plate) ; Caspary, Viert. f. Derm. u. 
Syph., 1884, p. 122; Bender, Virch. Archiv, clix., p. 1900; Hausteen, Festschrift f. 
Kaposi, 1900 (Archiv) ; Brown, J. Am. Med. Ass., 1907, xlix., p. 1671; Morton, N. 
Y. Med. Jour., 1895, June 8 (reprint) ; Eavogli, Ohio St. Med. Soc, 1901, May 7; 
Patek, C. J. D., 1904, xxii., p. 269 ; Ostermayer, Archiv, 1903, lxvii., p. 109 ; Baker, 
Exfoliative Dermatitis in the New-born (Bitter's Disease), N. Y. Med. J., 1906, 
June 9, p. 1184; Archiv, 1907, lxxxiii., p. 270; Monatshefte, 1907, xliv., p. 254. 



314 BYPElt&MlAS AND INFLAMMATIONS. 

Treatment. — The nutrition of the child should be sustained with 
proper feeding and the warmth of the body maintained. Locally the 
surface should be kept covered with a soothing oil or soft ointment, 
and care should be taken in changing dressings not to damage the 
sensitive skin. 

Prognosis is unfavorable, as about 50 per cent, of the infants 
affected with the disease die, the outcome depending largely on the 
strength and vitality of the child. 

EPIDEMIC EXFOLIATIVE DERMATITIS. 
(Epidemic Skin-disease (Savtll) ; Swim's Disease.) 

During the summer and autumn of 1801 an epidemic disorder 
with cutaneous symptoms developed in several London asylums, in- 
firmaries, and hospitals, affecting aboul five hundred patients. The 
disease was studied with special care by dermatologists and other 
medical men. The brief Bketch given below is based upon an excel- 
lent monograph with colored and photographic illusl rations by Savill, 1 
on various communications made on the subject in the columns of the 
British Medical Journal and the London Lancet for L892, and on the 
description given by Crocker in his treatise. American cases have 
been recorded by Fordyce, and Colby and Winfield. 

The disease occurred in two distinct clinical types, one with catar- 
rhal exudation from the skin, resembling the moist form- of eczema, 
the other dry and non-discharging, resembling pityriasis rubra, and, 
according to Crocker, indistinguishable from thai disease. 

The eruptive features were apparently nol preceded by prodro- 
mata, but gastro-intestinal disturbance (vomiting, diarrhoea), and in 
some cases Bore throal either preceded or accompanied the appear- 
ance of the dermatosis. Except in patients <»f advanced years, 
there was usually post-occipital and cervical adenopathy, nol to be 
explained as sympathetic with a cephalic erupt inn. The regions 
most frequently involved were the upper limbs, the scalp, and the 
face; the lower limbs less frequently. 

The skin-lesions were pruritic, and wore irregularly grouped, 
acuminate papules, with a follicular site. The face and upper ex- 
tremities were more extensively invaded than the lower extremities. 

The stages of the cxanthem, as given by Savill, were: 

a. A papulo-erythrmatous stage, lasting from three to eight 
days, in which shot-like papules were felt beneath the skin, were 
discrete, and were seated on a reddened, thickened, even an indur- 
ated or oedematous integument. In some cases the onset was in the 
form of marginate and circular nodose patches, resembling those seen 
in erythema nodosum; in a few cases the resemblance was to ring- 

1 An Epidemic of Skin-disease resembling Eczema and Pityriasis Eubra, by 
Thomas D. Savill, etc. Eondon, 1892. Also Monatshefte, 1892, xv.; Echeverria, 
E., B. J. D., 1895, p. 9, Histological Study in Unna's Laboratory: Fordyce J. C. 
D., 1897, p. 141 ; Colby and Winfried, J. C. D., 1898, p. 73. 



EPIDEMIC EXFOLIATIVE DEtiMATITIS. 31 5 

worm, flattened papules enlarging to a circinate annular group with 
minute central vesicles readily ruptured. 

b: An exudative stage, lasting from three to eight weeks, in 
which macules, vesicles, or papules soon formed a confluent eruption, 
the skin being of crimson hue, thickened, and scaling in flakes or in 
lamellated crusts in consequence of the exudation. In the moist 
type the papules developed to vesicles with exudation; in the dry 
type the exfoliation occurred in pure scales, pints of which in some 
cases could be collected from a patient's skin in a day. In other 
cases this exfoliation was in the form of an impalpable powder; it 
was characteristic of all well-marked cases. 

c. A stage of subsidence, in which the disease proceeded to invo- 
lution, leaving the skin at first indurated, polished, and brownish 
in color. In many cases the new skin was raw and parchment-like, 
smooth, shining, and readily fissured, resembling in this respect ich- 
thyosis. In a few instances ectropion resulted, as a sequel of con- 
junctivitis. In severe cases the hair and all the nails were shed. 
There was a mortality of from 5 to 13 per cent., death resulting from 
exhaustion with the usual signs of subsultus, shallow respiration, and 
coma. Complications occurred with pneumonia, gangrene, and albu- 
minuria. A few of the attendants upon the sick (children and 
patients of somewhat older years) were attacked; but for the most 
part the patients, and especially those succumbing to the disease, 
were individuals of advanced years of both sexes, inmates admitted 
for the management of other disorders to the institutions in which 
the disease prevailed. 

Etiology. — The cause of the disease was not satisfactorily deter- 
mined. Cocci were isolated and cultivated by Savill and Russell, 
but the etiological importance of these micro-organisms is yet to be 
demonstrated. Echeverria described a peculiar form of degenera- 
tion in the nuclei of the prickle-cells. The influence exerted upon 
the disease by parasiticides was beneficial to a degree ; but this treat- 
ment on the whole was unsatisfactory and chiefly amounted to 
amelioration of the conditions of the skin. 

PRIMARY EXFOLIATIVE DERMATITIS. 

Sir Erasmus Wilson was first to describe a primary form of exfo- 
liative dermatitis, distinct from pityriasis rubra in its career and 
termination, of which illustrations may be found in every large clini- 
cal experience. The disorder commonly begins with acute symptoms, 
malaise, chills, fever, and inappetence after which one or several 
regions of the body-surface steadily display light-tinted or deep red- 
dish, sometimes infiltrated, ill-defined patches, which after a varia- 
ble period (one to two weeks) spread over the general surface, after 
which the characteristic exfoliation occurs. 

The articular folds of the skin, the genital region, the head, and 
the trunk are most often the early seat of the disease, which may 



316 HYPEEMMIAS AND INFLAMMATIONS. 

involve consecutively one part after another. The affection may 
be limited to one region, or several distinct regions mav be involved 
simultaneously, as the head and the lower limbs, or the thorax and 
the external genitals. The hands and the feet are usually the last 
to be attacked. The eruption may appear in reddish patches of well- 
defined or of very indeterminate outline. The skin affected may be 
slightly or apparently not at all infiltrated and raised. The redness 
displayed in the regions affected with scaling may be of the brightest 
crimson, "erysipelatous," violaceous, or purplish shade, or with a 
faint suggestion of yellowness. The scales, which usually are formed 
in abundance, commonly are seen loosely covering the reddish integu- 
ment upon which they rest, though they are shed also in profusion 
when the affected surface is swept lightly with the hand. They are 
usually whitish and bran-like, but may be larger; they are as a rule 
larger and coarser upon the lower limbs than over the neck, face, and 
chest. 

In well-marked cases the features may be disfigured slightly by 
tumefaction of the lips, swelling of the ears, and puffinesa of the eye- 
lids. In most cases the skin is dry, bu1 rarely is moistened with a 
pathological discharge. Often there is coincidenl adenopathy. 

In the course of the disorder the hair- may fall, and in some 



Fig. 57 




Primary exfoliative dermatitis. 



cases the resulting alopecia is general. When the nails also are lost 
there is rarely any special preexisting onychia. The mucous sur- 
faces of the eyes, nose, mouth, and throat may participate in the 
general disorder and become the seat of inflammatory and, in rare 
cases, even of pseudo-membranous and exulcerative processes. 



PITY BIAS IS RUBRA PILARIS. 317 

Itching is usually absent; when present and severe it is relieved 
even before complete restoration of the integrity of the skin. 

The course of the disease is either to a slow but complete involu- 
tion or to the same termination with longer or shorter remissions, but 
it may terminate in a persistent universal exfoliative dermatitis. 

SECONDARY EXFOLIATIVE DERMATITIS. 

In this type of cutaneous exfoliation, the morbid process, even 
though exhibiting many of the symptoms heretofore described under 
the general title, actually follows in course of time, a precedent gener- 
alized psoriasis, 1 eczema, pityriasis rubra pilaris, lichen planus, or 
possibly a dermatitis medicamentosa, venenata, or traumatica. There 
may be acute attacks which subside, leaving the original disorder 
unmodified, or the process may be continued after the first or after 
successive attacks until a generalized or universal exfoliative derma- 
titis results, which is clinically and histologically indistinguishable 
from the conditions resulting from either of the two preceding types 
of the disease. 

In all forms of the disorder, and especially in the last two types, 
there may be complications due to secondary infection with pus- or 
other organisms, and to traumatism. In this way moist areas, also 
pustules, furuncles, and abscesses, may be present from time to time. 
In such cases local or generalized adenopathy may occur. 

PITYRIASIS RUBRA PILARIS. 

(Lichen Ruber [Hebra] ; Lichen Ruber Acuminatum [Kaposi]. 
Lichen-Psoriasis [Hutchinson] ; Pityriasis Pilaris [De- 
vergie] ; Fr., Pityriasis Rubra Pilaire.) 

Pityriasis rubra pilaris is a chronic, mildly inflammatory, ex- 
foliating disease of the skin in which the characteristic lesions are 
fine, acuminate, firm papules situated at the mouths of the hair 
follicles and displaying at the apex a horny plug or scale which dips 
into the follicle. By coalescence the papules form reddened, scaling 
areas which may spread and cover the entire surface of the body. 
This affection has been described chiefly in Prance by Devergie 
(in 1857), Besnier, Richaud, Brocq, and others. The museum of 
the St. Louis Hospital is provided with illustrations in wax, of every 
phase of the malady. Numerous illustrations of the disease have 
come under the observation of experts in America. The malady is 
undoubtedly identical with the lichen ruber acuminatus of Kaposi. 

Symptoms. — The disease usually begins insidiously, but may 
appear more or less suddenly, with or without mild systemic dis- 

1 Hoffmann describes a typical case of this character following psoriasis : 
Hoffmann, Dermatitis exfoliativa generalisata secundaria (nach Psoriasis vul- 
garis), Zeitschr., 1906, xiii., p. 660. 



318 



HYPEREMIAS AND INFLAMMATIONS. 



turbance. As a rule characteristic papules ("projecting cones") are 
not seen until after a period in which the disease appears as a sebor- 
rhea sicca of the scalp, with or without palmar and plantar scaling 
patches. The disorder may appear first on the face (nose, brow, 
lips, chin) as a fine pityriasis, or as a condition simulating sebor- 
rhea sicca. A similar fine desquamation may be present on the 
ears, neck, and other parts of the body, before the appearance of 
papules, but as a rule the latter appear on one or more regions soon 

Fig. 58. 



- 

MP 




•• \ 





Pityriasis rul> 



after the first evidence of the disorder and gradually extend to other 
portions of the body. The scales are seated at the follicular orifice- ; 
are thin, whitish, grayish, or heaped up in large discoid masses, are 
dry, firmly attached, friable, and in cases suggest the "crackle-ware" 
of the potteries. The disease is usually well marked over the ex- 
tremities and on the back of the neck, but may involve any or all 
portions of the body. Occasionally, in the acute type of the disorder, 
a large number of isolated papules appear somewhat suddenly over 
several regions, producing a condition simulating goose-flesh. 

The characteristic papules are minute, acuminate, hard, dry, and 
of a color varying from that of normal skin to the different shades 
of pink, rosy yellow, or duller hues. The papules are situated at the 
hair-follicles and each is pierced by a hair. At the apex of the 
papule, and surroimding the hair, is a horny sheath which penetrates 



PITYRIASIS RUBRA PILARIS. 319 

the hair-follicle for a short distance. Fine lanugo-hairs which pierce 
the papules, may be recognized on close inspection, the whitish horny 
plugs then giving the lesions a scale-capped appearance. 

The papules become more and more numerous, and appear at 
times to coalesce, and may form patches, at times symmetrically dis- 
posed, covered with tine elevations — conical and discrete ; or they 
may become round, flatter, and coalesce so completely as to be lost in 
the general scaling, exfoliating, erythematous, and lucent area. 
The yellowish red or deep-reddish patches may be the seat of pity- 
riasic scaling, or may exhibit separation of the epidermis in large, 
adherent flakes, which, especially over the elbows and the knees, 
present the appearance of psoriasis. When the infiltration is moder- 
ate, the intensifying of the natural lines of the skin is a conspicuous 
feature. The areas are irregular in size and shape, but frequently 
have an angular or oblong outline. Commonly at the borders of 
these patches are found the initial papules of the affection, still iso- 
lated and surrounding characteristic stumps, filaments, or black 
points of hairs, enabling one thus to make the diagnosis with ease. 

When discrete papules are grouped closely, and in areas formed 
by aggregation rather than by complete coalescence of the papules, 
a " nut-meg grater " effect is produced when the finger is passed 
over them. At times the eruption is generalized; when the face 
chiefly is involved, the slight crusts formed are decidedly of the type 
of those described under Dermatitis Seborrhoi'ca. In many cases the 
tension of the dry infiltrated skin produces ectropion of the lower lid. 
Occurring over the hairy scalp, the accumulated scales and crusts 
may form a dense and resisting cap which is difficult to remove. 
The nails are usually grayish, yellowish, transversely striated, and 
roughened. There may also be a coincident polytrichia. Impor- 
tant for purposes of diagnosis are the little horny, blackish, conical 
papillae occupying the site of the hair follicles on the dorsal surfaces 
of the first and second phalanges of the fingers. These usually re- 
main distinct even when, on all other parts of the body, their identity 
has been lost in the general exfoliative process. Sometimes an ex- 
ceedingly characteristic feature of the disease is displayed in the 
face, which on inspection seems to be covered with more or less firmly 
attached, irregularly creased, mortar-like plaster, the "cast" being 
conspicuously evident over the tip and root of the nose, the lower 
brow, the lips, and the chin. When the palms and soles are in- 
volved, they become the seat of a firm, thick, lamellar hyperkeratosis, 
reddish-yellow in hue, furnishing a " keratodermic sandal" (Besnier) 
for the sole. 

The course of the disease is usually chronic, irregular, and sub- 
ject to relapses and to unexpected exacerbations. The disease has a 
tendency to become generalized, and even universal, and to persist in- 
definitely. Periods of remission or of complete clearing of the 
skin are noted in a few instances, but the disorder usually returns. 
Of the score or more cases that have come under our observation, in 



320 HYPEREMIAS AND INFLAMMATIONS. 

four only have we seen the skin become entirely free from evidences 
of the disorder, though in most of the cases improvement was noted 
for varying periods. Of the four cases, in two, after periods of free- 
dom from the disease varying from a few months to five years, the 
cutaneous symptoms recurred, but not in severe type; in the other 
two the disorder was acute in its onset, becoming almost universal 
within ten weeks from its first appearance. In one of these patients 
who acquired syphilis soon after the appearance of the pityriasis 
rubra pilaris, the latter disappeared entirely in five months from its 
onset and had not recurred at the end of 6 years; the other was re- 
lieved completely at the end of nine months, but his subsequent 
history is unknown. 

Subjective sensation- may be entirely absent, though there is usu- 
ally a sense of dryness and of constriction of the skin. There may 
be more or less itching, though as a rule this is not marked. In the 
earlier stages at least, the general health appears to be unimpaired, 
even when the disorder is generalized. Eventually, however, in some 
cases there is more or Less failure of general nutrition leading in rare 
instances to a fatal result. 

Etiology. The cause of the disease is unknown. It commonly 
begins in the second decade of life, but has been observed at all ages, 
somewhat more often in men than in women. Cases are reported 
;it the age of two and a half years (Rasch) and at three years 
(Heller). 

Pathology. -Hodara, after histological investigation of two cases, 
recognized intlanmiatory changes in the cutis, thickening and infil- 
tration of the capillary 1>1 [-vessels, proliferation of the perithelia] 

cells, perivascular increase of the lymph-corpuscles, and mononuclear 
Leukocytes; proliferation and hypertrophy of the connective tissue of 
the cells of 1 1n- cutis and papillary Layer and slighl enlargement of the 
Lymph-vessels of the skin. In the epidermis was well-marked prolif- 
eration and hypertrophy of the rete, intercellular and parenchyma- 
tous; unmistakable thickening of the horny layer and marked hyper- 
keratosis of the stratum corneum. Hyperkeratotic horny plugs 
filled the follicular openings. These horny plugs were thickly dis- 
tributed over the palms of the hands. 

Milian regards the perifolliculitis of pityriasis rubra pilaris as 
probably due to tuberculosis. He recognizes that the essential fea- 
ture of the lesion is hyperkeratotic and perifollicular infiltration, the 
pilary plug being wholly subordinated to the last. 

Vignolo, after histological investigation of lesions in a patient 
forty-six years of age, finds that the epidermal changes are distinctly 
different from those occurring in lichen ruber. He regards the in- 
flammatory process in the corium as secondary to the epidermal 
changes. The author also recognized changes in the nerve endings 
(atrophy of Meissner's corpuscles) and an atrophy-producing sclero- 
sis of the communicating nerves. 

Eudokimow agrees with this view respecting the essential differ- 



PLATE VIII 

FIG. 1 




Pityriasis Rubra Pilaris. 

FIG. 2 




Pityriasis Rubra Pilaris. 



PITY EI A SIS BUBBA PI LABIS. 321 

ence between pityriasis rubra pilaris, and lichen ruber acuminatus. 

The histopathology given by Jacquet, Hodara, Taylor, Heidings- 
feld, Hartzell, Heller and others shows that the papule is the essen- 
tion lesion of the disease and is formed by hyperkeratosis of the 
epithelial layer of the superior portion of the hair-follicle. There 
is also abnormal cornification of the epidermis not limited to the 
hair-follicles. The mild inflammatory process in the corium is 
probably secondary to the epithelial changes. 

German cases (under the name of lichen ruber acuminatus) have 
been studied by Hebra, Kaposi, Neumann, Biesiadecki, Joseph, and 
others. The different reports vary considerably, depending appar- 
ently upon the age of the lesions examined. The morbid process 
corresponds closely to that described above, except for a more pro- 
nounced inflammation in the corium, as a result of which Kaposi and 
others believed the epithelial changes to be secondary to an inflamma- 
tion of the corium. 

Diagnosis. — The disease is to be differentiated from all others by 
the characteristic papule pierced by the shaft, or segment of shaft, 
of a hair. In extensive cases of long standing the identity of the 
papules may be lost in the general desquamation over most of the 
body; but in nearly all cases lesions can be recognized on the backs 
of the fingers, as described above. From lichen planus the diagnosis 
is not difficult in the early stages or when individual papules are 
found bordering the larger areas. The dull-crimson or violaceous 
hue of patches of lichen planus, is characteristic. Moreover, the 
disease is rarely so generalized as pityriasis rubra pilaris. Kera- 
tosis pilaris is limited, as a rule, to the regions which it chiefly af- 
fects, the extensor faces of the limbs. Ichthyosis is commonly con- 
genital, the first lesions developing soon after birth. In psoriasis the 
characteristic silvery-white imbricated scales, the bleeding points 
beneath, and the larger size of the primary lesions will usually es- 
tablish the diagnosis. In pityriasis rubra (of Hebra) the history 
of the disease, the absence of distinct papules and of infiltration, and 
the appearance later of atrophy of the skin are distinctive features. 
It must be remembered that rarely pityriasis rubra pilaris may termi- 
nate in a generalized exfoliative dermatitis which cannot be distin- 
guished from the same process arising from psoriasis, eczema, or other 
scaling affections (see Dermatitis exfoliativa). 

Treatment. — Systemic treatment should be varied to meet the in- 
dications in each individual. In many cases tonics, cod-liver oil, 
and an especially nutritious diet are indicated. Crocker praises 
thyroid extract, beginning with five grains (0.33) gradually and con- 
tinuously increased. Arsenic has given excellent results in some 
cases, but in a large number has failed; and apparently in a few 
instances has aggravated the disorder. We have had marked amelio- 
ration of the symptoms following the combined use of arsenous acid, 
grain %o (0.0033), and protoiodide of mercury, grain £ (0.01), 
three times a day, combined, however, with external applications. 

21 



322 HYPEREMIAS AND INFLAMMATIONS. 

The local treatment corresponds closely to that of psoriasis, squam- 
ous eczema, and other exfoliative conditions. The daily use of an 
ointment containing from 5 to 20 grains (0.33-1.30) of salicylic 
acid to the ounce (30.) of vaselin, or of equal parts of vaselin, lanolin, 
and olive oil, is often of value in keeping the skin soft and relieving 
the itching when present. For markedly thickened areas, ointments 
containing salicylic acid in strength of from 20 to 60 grains (1.33- 
4.) or more to the ounce (30.) may be used; or some of the prepara- 
tions of chrysarobin, resorcin, oil of cade, or ichthyol recommended 
for the treatment of psoriasis. Fatty crusts, when those are abun- 
dant, are to be removed by shampooings as in seborrheal affections 
of the scalp. 

Prognosis. — The prognosis is unfavorable with respect t<» the 
cutaneous manifestations, as in those eases in which the disorder 
disappears temporarily, it almost invariably recurs. The tendency 
of the disease is to persist indefinitely. The general health may be 
unimpaired, but is affected sooner or later in many instances. The 
issue in exceptional cases may be fatal. 1 

LICHEN RUBER.- 

(Gr., '/tiXrjx<, nm- 
(LlCIIEH RUBBB AriMlNATls. (!rr., RoTHE St ll WIND] I I I IB I I . ) 

Under the term lichen ruber, Hebra was firs! i" describe a disease 
which corresponds closely i<> the disorder described in these pages as 
pityriasis rubra pilaris. All of Hebra's cases, however, wen- a--', 
eiated with grave Bystemic conditions and terminated fatally. Ka- 
posi Intel' described a lichen ruber acuminatus which he states is 
identical with the lichen ruber of Hebra, though in his case- the 
general health of the patient is not s<> seriously affected. The exact 
relationship existing between the cases described under these three 
lilies has been the Bubjed of much discussion, but at an Interna- 
tional Dermatological Congress, a ease was claimed as typical lichen 
ruber acuminatus by Kaposi and other Germans and as typical pity- 
riasis rubra pilaris by different French authorities. Critical com- 
parison of the literature and illustrations of the subject removes all 

'Bibliography: Besnier. Annales, 1889, s. ii.. pp. 253. 398. 485; Eichaud, These 
.1c Paris. 1S77; Thibierge. La Prat. Derm.. 1902. T. iii.. p. 886; Taylor, N. Y. Med. 
Journ.. Jan.. 18S9; Brocq, Annales, 1889, s. ii.. x.. p. 301; Ranch, Centralb., 1899, 
ii., p. 199; Heller, Zeits., 1903. x., p. 153 (with histological study); Milian, An- 
nales, 1906, s. iv.. vii., pp. 1067-1075; Vignolo, Archiv. 1906, lxxix., pp. 273-292, 
Eudokimow, Bussi. Zeits. f. Haut- and Vener. Krankheit., 1905, Bd. 9. 

2 Literature bearing on the subject: Discussion in Trans. Internat. Cong, of 
Derm, and Syph., Paris, 1SS9; Besnier, Annales, 1889, s. ii.. x., p. 322 (monograph, 
with colored illustrations and full discussion of entire question) ; Kaposi, Archiv, 
1S89, xxi., p. 743, and 1895. xxxi.. p. 1 ; Robinson, J. C. D., 1889, vii., p. 41 (with 
colored illustrations); Taylor (R. W.), N. Y. Med. Jour., January 5, 1889, p. 1 
(with histology) ; Neisser, Verh. d. deutschen Derm. Gesell., IV. Cong., p. 495 
(with discussion); Hans v. Hebra, B. J. D., 1890, ii., p. 65; Neumann, Archiv, 
1892, xxiv., p. 3; Verh. d. Berlin. Derm. Gesell., 1901-2, p. 118; and discussion be- 
fore N. Y. Derm. Soc. ; J. C. D., 1902, xx., p. 572, 



LICHEN PLANUS. 



323 



doubt that pityriasis rubra pilaris and lichen ruber acuminatus 
(Kaposi) are one and the same disease. Hebra's lichen ruber, judg- 
ing from Kaposi's statements and from two plates (to which Crocker 
calls attention), published by Hebra, was probably a severe form 
of the same disease. 

A few German authorities still teach that pityriasis rubra pilaris 
is wholly distinct from lichen ruber, which they subdivide into lichen 
ruber acuminatus and lichen ruber planus. Instances are cited by 
Kaposi, Neumann, and others, in which the acuminate and the plane 
papules coexisted in the same individual. These few cases are 
probably coincidences or modifications of usual types, and lichen 
planus is held generally to be a disease entirely independent of lichen 
ruber. 

LICHEN PLANUS. 

(Gr., ~ktixr,v, Lat., planus, flat.) 

(Lichen Ruber Planus, Lichen Psoriasis.) 

Lichen planus is an inflammatory dermatosis, in which are dis- 
played multiple, small, flat-topped, angular or polygonal papules, 
often exhibiting a color containing various shades of crimson or 
purple, the plane apex of each being usually flat or depressed and 

Fig. 59. 




Lichen planus. 

covered with a horny film. This disease was described first by Eras- 
mus Wilson in 1869, and although in typical development its dis- 
tinctive features are pronounced, much discussion has existed re- 
guarding its relation to lichen ruber acuminatus (Kaposi). Under 
the latter title the reader will find paragraphs devoted to this dis- 
cussion. The disorder is of frequent occurrence, though it is not 



324 HYPEREMIAS AND INFLAMMATIONS. 

one of the common diseases of the skin. It is usually chronic, but 
may be acute, and although in most instances limited in distribu- 
tion it may be extensive and even generalized. 

Symptoms. — In a typical case of lichen planus the primary 
lesions are pin-point- to pin-head-sized, angular or polygonal, flat, pap- 
ules. These are sharply defined, and covered not with a scale, but 
with a thin, translucent, horny film, which gives the lesions a waxy 

Fig. 60. 



Lichen planus. (Fox.) 

or varnished appearance. As the papules increase in size they retain 
their angular or polygonal outline and remain flat, or may become 
slightly umbilicated. The bases are rounded or angular and the 
sides precipitate. The color of recent lesions is a bright crimson, 
that of the older a dull crimson or reddish purple. The greatest 
diameter attained by any individual papule is about one-half that of 
a small split-pea, but by coalescence the original lesions may form 
larger areas which are also angular, linear, or polygonal in outline, 
and arc defined sharply from the surrounding -kin. On the patches 
the thin horny covering may partially be broken up into very fine, 
closely adherent scales. The surface may show fine white striae. 
The favorite sites of the disease are the flexor surfaces of the wrist 
and forearm, and the legs immediately above the ankles, though 
any part of the body may be involved. Itching is usually intense 
and rarely absent though in some cases it is much less severe than in 
others. 

The elementary lesion of every classically developed eruption is 
a flat-topped or slightly umbilicated, angular or polygonal, slightly 
elevated, sharply outlined papule, which when studied in different 
positions so that the light falls aslant upon the surface, exhibits 
a characteristic glistening or shining top shown in no other eruption. 
On the surface of larger papules may be seen, on close inspection, 
minute whitish points and lines to which Wickham first called atten- 
tion. The papules exhibit a peculiar crimson or purplish shade, 



LICHEN PLANUS, 325 

and when the eruption is plentiful this color is so characteristic 
that by it alone in a well-marked case the eruption may be recognized 
by the eye before individual lesions can be identified. The papules 
vary in size from that of the head of a small pin to one-half that of a 
split-pea. Rarely they may be larger, or round instead of angular, or 
an occasional papule may enlarge peripherally to form a circle half 
an inch or more in diameter with depressed centre. 

As the lesions grow older they almost invariably distinctly deepen 
in shade, from a light-crimson to a dull-purplish hue, and still later 
to even a darker color. Involution of the papules often leaves a 
pigmentation of a smoky, sepia, or even blackish hue, which is natur- 
ally most conspicuous and most persistent on the lower extremities. 
Occasionally white, atrophic-looking spots are left, which ultimately 
disappear. 

The lesions may be discrete and isolated, or irregularly grouped, 
but when numerous they tend by multiplication and aggregation to 
form irregular, linear, angular or polygonal patches with sharp out- 
lines. Annular or circinate patches may occur (Lichen planus 
annularis). Rarely combinations of lines and circinate groups form 
exceedingly odd-looking figures, parellel lines, cockades, scaling crests, 
rings, rosettes, etc. The shape of the patch may be determined 
by an external irritation, such as a scratch-mark. 

When the papules coalesce and lose their identity, a crimson- 
hued sheet or mask of the skin is seen, generally characterized not 
merely by the color of the lichen-papules, but also by a silvery 
sheen, due to thin shining scales which do not completely cover, 
but which supplement, as it were, the empurpled patches, beside and 
over which they form. These scales are not freely shed from the 
surface, but are attached firmly. When there are decided sheets 
of infiltration they are most conspicuous over the flanks and belly, 
but they may also be seen elsewhere, as, for example, over the ex- 
tremities. When the patches undergo involution, the scaling ceases, 
the infiltration subsides, and the intensely deep pigmentation left is 
characteristic of the disease, being often of a smoky, and even of a 
blackish hue. Later slight atrophy may appear for a time, but 
permanent scarring is seen rarely if ever. After the disease has 
existed for a long time, a single band-like plaque may lose almost 
all papular features, and come to resemble a deep-purplish keloid- 
like elevation or flat tumor imbedded in the skin; more commonly 
the majority of the papules are lost in the formation of flat-topped, 
brownish-red, pea- to bean-sized or larger elevations commingled with 
sepia-brown pigmented spots (lichen planus hypertrophicus) . Such 
nodes, ridges, or patches may be elevated one-fourth of an inch or 
more above the level of the skin, and may be covered with adherent 
horny scales or with pointed horny projections which give the lesions 
a warty appearance (lichen planus verrucosus). The hypertrophic 
forms in moderate development may be seen occasionally about the 



326 



HYPEREMIAS AND INFLAMMATIONS. 



genitals as a result of long-continued infiltration and traumatism 
from scratching. 

The disease, though usually limited to a few regions, is sym- 
metrical as a rule, but may appear on one side only of the body. 
The eruption may cover large areas, and in rare instances the entire 
surface of the body. The favorite sites arc the flexor surface of 
the wrist and forearm, and the leg below the knee. The disease 
may appear on any part of the body, but is seen rarely on the 
face or seal]), and is unusual on the palms and soles. 1 The nails may 
be involved and present lesions similar to those seen in psoriasis and 

eczema. 

Fig. 61. 




Lichen ruber moniliformis. 



The greatest variation is experienced in the way of subjective 
sensations. In some patients the eruption is tolerated with but few 
symptoms of annoyance. Tn other patients the ,L r reat<-r possible 
distress is occasioned, and no subjects of scabies or of eczema suffer 
more. The eruption of lichen planus, however, is scratched less 
1 Cf. Dubreuilh and Le Strat, Annates, 1902, s. iii., iii., p. 209. 



LICHEN PLANUS. 327 

often than that of other cutaneous exanthemata accompanied by 
severe pruritus. 

The course of the disease is chronic, and when untreated it may 
last for months or years, either through persistence of the original 
papules and areas, or, what is more frequent, by the successive ap- 
pearance of new lesions. Occasionally the disease disappears spon- 
taneously but its tendency is to persist. The disease may recur, but 
recurrence is an exception to the rule. 

Rarely lichen planus may begin as an acute exanthem, becom- 
ing generalized in a few days, or even within twenty-four hours. In 
such cases the lesions are usually minute, of bright color, and exhibit 
no tendency to definite grouping. There may be coincident febrile 
symptoms and mild systemic disturbance or severe concomitant dis- 
orders such as pemphigus, diabetes, syphilis, and grave ulceration. 1 
These acute symptoms may develop in individuals previously free 
from all evidence of lichen planus, but more commonly in those who 
have exhibited for months or years one or more areas of the disease, 
which then may run an acute course of a few weeks yielding readily 
to treatment or may persist as a generalized or localized chronic f otm. 

As a rule the general health is not involved save when the itch- 
ing is so severe as to interfere with the patient's sleep and rest. 
Crocker refers to generalized cases in which the health was affected 
profoundly, a few of which terminated fatally. In this country one 
such case has been reported by Fordyce, 2 but it is not clear that the 
severe systemic disorders present in these cases have had any direct 
relation to the lichen planus. 

A number of variations from the usual clinical types occur. 3 
On the legs and forearms, and occasionally on other parts of the 
body, rounded or oval, flat or slightly convex papules may develop to 
the size of a pea or bean (lichen planus obtusus). Kaposi, Gunsett, 4 
and others report cases under the name of lichen ruber moniliformis 
in which numerous node-like masses are arranged in lines and bands 
resembling a necklace of beads, with flattish, punctiform papules, 
and macules of a sepia-brown hue between the nodes. 5 When the 
lesions especially over the lower extremities have existed for some 
time, they may become elevated, warty and verrucous, losing their 
earlier smooth aspect (Lichen planus verrucosus). 

The tendency of lichen planus papules to form linear groups, or 
bands may be exaggerated to produce the type known as lichen 
planus linearis.® In such cases a narrow fillet of typical lesions 
may extend from the heel to the trunk along the line of the sciatic 

1 Johnston, J. C. D., 1907, xxv., p. 86 ; Galloway, B. J. D., 1906, xviii., p. 66. 
* Trans. Amer. Derm. Assoc, 1898. 

3 Crocker, B. J. D., 1900, xii., p. 421 (with discussion before the London Der- 
matological Society). 

*Archiv, 1902, lx., p. 179 (with histological report and bibliography). 

5 A case of " moniliform lichen ruber " was shown by the author to the 
Chicago Dermatological Society in the year 1908. 

6 Cf. Heller, Archiv, 1898, xlii., p. 59, and Whitfield, B. J. D., 1906, 18, 221 
(with references to previously published eases of this type). 



328 HYPEREMIAS AND INFLAMMATIONS. 

or other nerve, or, more frequently, from the buttock to a few inches 
below the knee. Such a case recently came under our observation. 
A similar arrangement of lesions may occur along the course of the 
nerves of the upper extremity or on the trunk. Again, the bands 
may be absolutely straight and apparently independent of the course 
of any nerve. Galloway has reported a striking example of this 
type, 1 and we have had a similar case, but less extensive, on the outer 
surface of the thigh and leg. 

Vesicles at the summit of some of the papules, and bulla? occur 
in a number of cases of lichen planus, most frequently in patients 
who have been taking arsenic, but also in others who had taken no 
arsenic prior to the appearance of the moist lesions. Trautmann 2 
has described a case in which pemphigus appeared to follow an attack 
of lichen planus. Whitfield, 3 in presenting a patient, analyzed sev- 
enteen previously reported cases, in nine of which the patient had 
taken no arsenic prior to the appearance of bullae. He states that 
the presence of bullae apparently has no bearing on the severity or 
prognosis of the disease. 

Under the title Lichen Planus Erythematosus, Crocker describes 
two cases in which the papules were of a deep-crimson tint, soft to 
the touch, and obliterated temporarily by pressure. There was in 
both a marked telangiectasia of the face. Crocker mentions a similar 
case reported by Stirling. 

Lichen planus is of rare occurrence in children. Crocker, Liver- 
ing, and Colcott Fox all report a spurious form which the author tii-t 
named believes to be a subsiding stage of papular or vesicular miliaria 
rubra. In Whitfield's case of linear lichen planus, the patient was 
a child aged O 1 ^ years. The lesions in children are much like those 
in adults. 

Etiology. — The causes of lichen planus are obscure. It is often 
difficult to recognize the sources of the disease, but in many cases a 
history of nervous exhaustion can be obtained. One of our patient-, 
a married woman, displayed the disease in an aggravated form almost 
immediately after the body of her husband who had been burned to 
death was brought to her door. Grief, long-continued anxiety, and 
overwork, especially when accompanied by great mental strain, fre- 
quently precede this disorder. Many patients are well nourished 
and not lacking in flesh. In fact, the combination of a fair degree of 
nutrition of the body with nervous exhaustion is to be recognized fre- 
quently in patients affected with lichen planus. 

Other causes cited are: traumatism (dog-bite, Walters), digestive 
disturbances, malaria, malnutrition, and diseases of the generative 
organs. Lichen planus is most common after the second decade of 
life, and is rare in children. Different opinions are entertained 

1; B. J. D., 1900, xii., p. 206. 

2 Derm. Zeitschft., 1906. 307. 

3 B. J. D.. 1902. xiv.. p. 161; see also Allen, J. C. D., 1902, xx., p. 260 (report 
of two cases with reference to others previously recorded and discussion before 
Amer. Derm. Assoc). 



LICHEN PLANUS. 329 

respecting the frequency with which men and women are attacked. 
General experience points to the conclusions formulated by Crocker, 
who reports more cases among (English) women than among men, 
while the statistics of the Vienna school reverse the figures. The 
disease is encountered more frequently in private practice among the 
nervously taxed of the well-to-do classes than among out-patients of 
public charities, who suffer to a greater extent than others from cach- 
exia and malnutrition. Russell lately reported a case in which the 
disease followed amputation of four fingers of the right hand. Hoff- 
mann 1 reports the coexistence of lichen planus with diabetes. 

The fact that lesions develop along scratch-lines in predisposed 
individuals leads Jacquet to state that lichen planus is always trau- 
matic, and found in individuals with a diminished vasomotor tonus, 
resulting from some disturbance of the nervous centres. Hallopeau 
and Jomier, 2 on the other hand, bring forward as evidence of the para- 
sitic origin of the disease a case in which lichen planus lesions devel- 
oped along scratch-marks in an individual who had never had the 
disease. A similar case is reported by West 3 in which the scratch- 
marks were produced by a cat. 

Pathology. — Robinson first clearly showed the pathological dis- 
tinction between lichen ruber and lichen planus. His observations 
have been confirmed by those of Boeck, Kaposi, Touton, Weyl, and 
others. Among reporters on the histopathology of the disease may be 
mentioned Crocker, Torok, 4 Joseph, 5 and Pinkus. 6 

The genesis of the disease, though not understood, is probably 
neuropathic. Colcott Fox suggests a neuroparalytic hyperemia as 
the first stage of the process. The corium shows dilatation of the 
vessels, cedema, and cell-infiltration which is limited to the papillae and 
to the subpapillary layer, where it is defined sharply from normal 
tissue beneath. This sharp definition is characteristic of the process. 
The papillae usually are enlarged. The cells are reported by some 
observers to be leucocytes; by others as of connective-tissue origin. 
It is probable that in the early and acute stages leucocytes predomi- 
nate. In some instances polymorphonuclears are conspicuous, while 
new connective-tissue cells will be found in lesions of longer duration. 

The epidermal changes also vary considerably according to the 
stage and acuity of the process. In acute cases with much infiltration 
of the corium the rete may be thinner than normal as a result of 
pressure. There is often, however, early in the process more or less 
hyperplasia and intercellular oedema of the rete. Unna states that 
the epithelium shows first a hyperplasia of the prickle-cells with inter- 
cellular (edema, increase in the granular layer, and hyperkeratosis of 
the horny layer. As the papule enlarges the centre shows an atrophic 

1 Annales, 1906, s. iv., vii., p. 420. 

2 Annales, 1903, s. iv., iv., p. 352." 

3 B. J. D., 1897, ix., p. 162. 

4 Jour. mal. cutan., 1889, s. 6, i., p. 162 (with bibliography). 

5 Archiv, 1897, xxxviii., p. 3. 

"Ibid., 1902, lx., p. 163 (3 plates and references to literature). 



330 HYPEREMIAS AND INFLAMMATIONS. 

thinning of the rete and a more compact horny layer which, resting 
upon the flattened rete, gives the papule its umbilicated aspect. The 
density of the horny layer covering the papule gives the latter its 
glazed appearance and explains the lack of exfoliation in scales. 

The process frequently begins about the ducts of the coil-glands, 
though the glands themselves rarely are involved. The hair-follicles 
and sebaceous glands also escape. 

Crocker states that the greatest thickening of the horny layer oc- 
curs at the centre of the papule at the opening of the sweat-duet into 
which the horny mass projects, and that the desquamation of this plug 
leaves a depression or umbilication of the papule. 

Joseph, 1 Whitfield, and others have reported the formation of 
small vesicle-like cavities in the basal layer. Joseph explains the um- 
bilication of the papule by absorption of these pseudo-vesicles. 

Diagnosis. — The diagnosis rests upon the characteristic features 
heretofore described. Thus, in its size, apex, color, and course the 
papule of papular eczema is quite different from that described 
above, being brighter, redder, more acuminate at the apex, and much 
more often followed or accompanied by catarrhal symptoms in the 
skin. In psoriasis punctata the scales are abundant and readily 
removed ; the individual lesions are increased rapidly by peripheral 
extension, far beyond the fullest development of the papule of 
lichen. The papular syphiloderm is not, as a rule, pruritic, not 
flattened when minute, not polygonal in shape, and not covered 
with a closely adherent horny scale, and it always occurs in patients 
in whom careful investigation discloses other symptoms of the dis- 
ease (mucous patches, adenopathy, etc.). The history and course of 
the disease will determine the diagnosis. 

Chronic lesions of lichen planus on the legs (obtuse, verrucous, 
hypertrophic) have been confused with the condition of the same 
parts developed in Kaposi's multiple idiopathic pigmented sarcoma. 
In the disorder last named, the elephantiasic aspect of the limb, the 
infiltration of the integument, especially at the root of the toes, and 
the characteristic roundish nodules springing from the general sur- 
face, suffice to render the diagnosis facile. 

The distinctions noted above in connection with lichenification of 
patches of chronic inflammation of the skin arc not to be disregarded. 

Treatment. — Systemic treatment depends upon the condition of 
the patient. As many of the subjects of lichen planus are neurotic, 
neurasthenic, or suffering from other depressing or debilitating con- 
ditions, it follows that in many instances it is necessary carefully to 
regulate the diet, habits of rest, sleep, and exercise, and to administer 
tonics, cod-liver oil, and other remedies which will build up the gen- 
eral health. In some instances a change of climate, scene, and occu- 
pation is of the greatest value. 

Arsenic, though sometimes causing an aggravation of the symp- 
toms in acute cases, is a valuable remedy in many subacute or chronic 

1 Loc. cit. 



LICHEN PLANUS. 331 

and extensive cases of the disease. It may be given as directed for 
the treatment of psoriasis. Mercury in the form of the biniodide, bi- 
chloride, or the protoiodide, is increasingly recognized as of unques- 
tioned value in many cases. The protoiodide, grain % (0.01), with or 
without arsenous acid, grain 34o (0.0033), may be given three times 
a day. Crocker recommends the use of salicin in 15-grain (1.0) 
doses three times a day and large doses of quinine in an effervescent 
mixture. Tilbury Fox and Eobinson found the alkaline diuretics 
taken well diluted after meals of value, especially in the generalized 
hypergemic cases. For very acute cases we have found the remedy 
of value at times in relieving excessive itching. Aspirin in 5-grain 
(0.33) doses may be used for the same purpose. Hartzell 1 advocates 
the employment of the salicylates. 

Local treatment should be directed toward the protection of the 
skin and the relief of itching. For many cases the use of a paste and 
dusting-powder as described in the treatment of eczema and psoriasis 
gives satisfactory results. A paste containing equal parts of lanolin, 
vaselin, zinc-oxide, and talcum, with from 1 to 3 per cent, of salicylic 
acid, is usually effective. In very acute and extensive cases more 
relief sometimes is obtained by the use of the soothing lotions and 
dusting-powders recommended for the treatment of the acute stages 
of eczema. The same care should be taken as in eczema to have the 
clothing next the skin of soft cotton or linen. In many instances 
bathing once a day in tepid oatmeal- or bran-water, with or without 
the addition of an alkali, may precede the application of the paste or 
other remedy. Some patients, especially those with much scaling 
and infiltration of the skin, are made more comfortable with the use 
of ointments than with pastes. In subacute and chronic cases tar in 
the form of lotion, ointment, or paste, is often of value. Directions 
for its use are given in the section on eczema. For stubborn patches 
the treatment differs little from that recommended for inveterate 
psoriasis. For hypertrophic areas, salicylic acid is most effective. It 
may be applied in a paste or ointment containing from 30 to 60 
grains (2.-4.) to the ounce (30.), or better, it may be dissolved in 
equal parts of alcohol and ether, and the solution painted on the patch. 
The alcohol and ether evaporate and leave the acid in contact with the 
lesion. After a sufficient amount has been applied, the whole may be 
covered with adhesive plaster. The dressing should be changed every 
day or two, and when the part becomes greatly inflamed a soothing 
dressing should be substituted. Brocq and Jacquet recommend the 
daily use of a tepid douche for from two to ten minutes at a time, 
alternated with the application for a few seconds of a cold spray. 

For chronic cases with much infiltration, the x-rays are indicated. 
We have used the method, in conjunction with other treatment, in a 
large number of cases with decided improvement, including relief of 
itching in all, and unusually rapid recovery. The number of ex- 
posures in each case varied from two to nine, and the technique was 
that commonly employed for psoriasis. 

1 J. A. M. A., July 20, 1907, 225. 



332 HYPEREMIAS AND INFLAMMATIONS. 

Prognosis. — The prognosis is in general favorable, since even cases 
of long standing usually are relieved when the subjects of the disease 
are placed under conditions favorable for recovery. When the patient 
is neurasthenic the eruptive symptoms may persist for years, accom- 
panied by intense itching and a consequent teasing of the nervous 
centres. In this class of subjects it is generally well to make a 
guarded prognosis, and to pronounce upon the future with reserve. 

LICHEN PLANUS ANNULARIS. 

In some cases, the papules of lichen planus, while extending 
peripherally, leave a cleared or clearing centre, and form thus circu- 
lar patches in thin rings or bands, at times coalescing in polycyclic 
outlines. The patches may be few or numerous; the rings, faintly 
or very distinctly outlined ; the component parts of the ring, the char- 
acteristic papules of lichen planus, either readily distinguishable or 
so fused as to render their identification difficult. 

Wholly different from this condition is that denominated Granu- 
loma Annulare — designated by some authors as lichen annularis — 
the paragraphs devoted to which in this treatise may be compared 
with the preceding pages. It is true that some authors believe the 
conditions named are, if not identical, at least allied ; but our experi- 
ence (cited by Graham Little who has studied the subject exhaust- 
ively) leads the author to believe that the essential lesion in each is 
not the same. 

It is rare that the classical papule of lichen planus is to be 
recognized in typical granuloma annulare: this last occurs in chil- 
dren, but also often in gouty patients in middle or later life. The 
lesions are disposed on the hands chiefly (lichen annularis is more 
often displayed on the trunk). The individual elements in granu- 
loma annulare are smooth, flattened nodules rather than papules ; 
pale, ivory-like or slightly reddened. When fused the annular patch 
is elevated one or two millimetres above the general level of the skin. 
The fused ring is firm, distinctly circumscribed, the skin of the en- 
closed area having a normal aspect, at times suggesting that super- 
ficial atrophy has taken place. 

LICHEN PLANUS MORPH(EICUS. 

Lichen planus Scletcosus et Atkoptttcus (Crocker and Stow- 
ers). — This is one of the rarer forms of lichen planus, the lesions 
in their size, shape, firmness, evolution, and grouping, not greatly 
differing from the more common types. The papules are, however, 
somewhat whiter than others and differ also in the prominence of the 
horny pings projected from each. After the easting of the ping the 
papule undergoes a1 its depressed centre a distind atrophy, while in 
some a narrow reddish or pigmented /.one produces a picture strikingly 
suggestive of morphcra, whence the title given the lesions by Crocker. 



LICEEN PLANUS MORPHCEICUS. 333 

Montgomery and Ormsby, however, have distinctly differentiated the 
two disorders from "White Spot Disease" (morphoea guttata). 

Dubreuilh has called attention to a point of striking import in 
this connection, viz., that a group of dermatoses variously denomi- 
nated by authors, lichen morphoeicus, circumscribed guttate sclero- 

Fig. 62. 




Lichen planus atrophicus. 

dermia, circumscribed cutaneous atrophy, atypical lupus erythema- 
tosus, " vergetures rondes" etc., may be, one or all, examples of 
atrophic and sclerous lichen planus. 

In typical cases the papules are grouped, six, eight or more in a 
single cluster, the individual elements being smooth, shining, whitish 
or rose-reddish, slightly elevated, facetted at the sides, striated finely 
at the summit, firm, dry, and plugged, each with a horny central mass. 
These even at a short distance resemble comedo-plugs, being blackish 
points, of which at the summit of a single lesion, as many as five or 
six may be seated each in a distinct depression in the integument. 

Histologically, these lesions do not differ from those of the usual 
type of the disease, save that the areas of cellular infiltration are 
rather more deeply seated and separated from the overlying epiderm 
by a layer of distinct sclerotic tissue. Montgomery and Ormsby tak- 
ing the broad view of these conditions, believe that a close relationship 
exists between the atrophic forms of lichen planus, and morphoea 
as well as the macular and striate atrophies of the skin. 

Literature. 

For complete bibliography, see Brocq, loc. cit.; Zarubin, Archiv, 1901, lviii., 
p. 323; Biecke, Mracek's " Handbuch der Hautkrankheiten, ' ' Vol. ii., p. 595. 

Montgomery and Ormsby: J. C. D., Jan., 1907 (reprint). 

Dubreuilh and Petges: Annales, 1907, s. iv., viii., p. 715. 

Hallopeau: Annales, 1889, s. ii., x., p. 447; 1896, s. iii., vii., p. 57; 1898, s. iii.. 
ix., p. 358. 

Darier: Annales, 1892, s. iii., iii., p. 833. 

Brocq: La Prat. Derm., t. iii., p. 207. 

Stowers: Intern. Derm. Cong., London, 1896, p. 906. 

Orbeck: Archiv, 1899, 1., p. 393. 

Crocker: Brit, Med, Jour., 1900, xli., p. 42L 



334 HYPEEJEMIAS AND INFLAMMATIONS. 

LICHEN SPINULOSUS. 

(Liciiex Pilaris.) 

Under the titles named above Radcliffe-Crocker, Adamson, Bowen, 
Pringle, and others have described a condition in which filiform 
spines are developed from lesions of lichen planus, usually in sym- 
metrical disposition, occurring more often in boys and children than 
in adults. Somewhat more than a score of cases have been observed. 
Horny plugs or spines, giving to the finger the sensation of touching 
a nutmeg grater, some of them with flattened tops, occur in groups 
upon patches of the skin which are infiltrated and indurated. The 
papules from which the spines project are usually miliary or acumi- 
nate, and situated at the pilo-sebaceous follicles, occurring on the face 
( forehead), neck, ears, and extremities, thigh, leg, and upper and 
lower arms, and in some cases commingled with the ordinary lesions 
of lichen planus ; in some others with papules suggesting keratosis 
pilaris ; yet other cases are associated with patches of lichenification. 
The papules are sometimes lighter colored ; at times of a dark brown- 
ish hue, and in cases they are interspersed with dull, red maculo- 
papules. Often a hair may be seen piercing the separate lesions. The 
eruptive symptoms are to be distinguished from those occurring in 
Hallopeau's acne cornee; from pityriasis rubra pilaris; from lichen 
scrofulosorum ; and from the miliary syphiloderm. 

In Brooke's keratosis follicularis contagiosa, delicate horny spines 
have sometimes been recognized and the distinction between these 
last and the disorder under consideration may be difficult, if at all 
possible, to establish. 

Pathology. — Histological examination of the plugs establishes the 
fact that they are made up of concentric lamella cylindrically dis- 
posed about an atrophied hair. The horny masses are made up of 
welded flattened epithelial cells. The walls of the containing plug 
are thinned toward the follicular orifice, and widened below where 
there is acanthosis. There are no keratohyalin granules; no sebace- 
ous glands; the sweat glands are not attacked, and the hair bulb is 
unaltered. 

Bibliography. 

Bowen: J. C. D., 1906, xxiv., p. 416. 

Adamson: B. J. D., 1905, March, xvii., p. 77. Review of all cases up to date. 
Two figures. 

Pringle: B. J. D., 1S97, ix., p. 74. 
f'olcott, Fox: ibid., 1902, xiv., p. 91. 
Lewendowsky: Archiv, 1905, Feb. 2 and 3, p. 343. 

LICHEN ANNULARIS. 

Lichen annularis (ringed eruption of the extremities) is a title 
given by Galloway 1 to a case in which several lesions having pale, 
irregular, elevated borders showing circular or circinate outlines, de- 

1 B. J. D., 1899, xi., p. 221 (with clinical (colored) and histological plates, and 
abstracts of similar cases previously reported). 



LICHEN PLANUS OF THE MUCOUS SURFACES. 335 

veloped about the joints of the hands. The border was elevated one 
or two millimetres ; the lesion was about three millimetres in breadth ; 
smooth, hard; and not reddened, but suggesting deep-seated infiltra- 
tion of the cutis. The folds of the skin about the joints divided the 
border in places, giving it a nodular appearance. The lesions were 
slow of evolution and indolent in career. The skin of the enclosed 
area was almost sound, but showed slight signs of atrophy when the 
original process had undergone involution. The histological structure 
closely resembled that of lichen planus. The lesions flattened rapidly 
under the application of salicylic acid in ointment. We have had 
similar cases. The lesions were limited to the forefinger and thumb 
of one hand, and entirely disappeared in the course of a year under 
somewhat irregular treatment with a 50 per cent, aqueous solution 
of ichthyol, after salicylic acid had been used several months without 
effect. Crocker 1 describes five similar cases and refers to others 
reported. 

LICHEN PLANUS OF THE MUCOUS SURFACES. 

Lichen planus of mucous surfaces 2 (tongue, inner face of the 
cheeks, lips, epiglottis, glans penis, progenital region of both sexes ; 
anus and peri-anal region) may occur without cutaneous symptoms, 
or accompany these last. In some cases of well-marked cutaneous 
disease the mucous membranes are so slightly affected or attract so 
little attention that they are overlooked. Dubreuilh believes that 
more cases of involvement of mucous membranes occur without cu- 
taneous lesions than of the last named without mucous symptoms. 
Confusion has been bred in these cases by the hastily formed con- 
clusion that the lesions here discussed are mucous patches or symp- 
toms of leukokeratosis buccalis. 

Pinhead to hemp-seed sized, grouped or isolated, slightly pro- 
jecting, velvety, smooth, grayish, whitish, rounded, projecting lesions 
may be recognized as lesions of lichen planus of the mucous surfaces, 
the color and size varying somewhat with the individual, the age of 
the disorder, and the locality involved. Sometimes a slight halo 
surrounds the base of each; at times they are firm, at others soft to 
the touch. Again they may send short ramifying striae to the neigh- 
boring mucous surfaces. As distinguished from purely cutaneous 
lesions they may be smeared with a whitish mucus. Histologically 
the picture does not greatly differ from that recognized in sections of 
nodules removed from the skin. The principal focus of disease is 
found in the papillary and sub-papillary layers of the corium, where 

1 Diseases of the Skin, 3d Ed., p. 1082. 

2 Literature : Neumann, Tiber die Localisation des Lichen planus auf der Schleim- 
haut, Weiner med. Wochenschr., 1906, 17; Archiv, 1906, lxxxii., p. 469. Poor, 
The Anatomy of Lichen Planus of the Mucous Membranes, Derm. Zeitschr., 1905, 
xii., pp. 605, 645; B. J. D., 1906, xviii., p. 227; Annales, 1906, s. iv., vii., p. 421; 
Monatshefte, 1905, 41, p. 623; Archiv, 1907, lxxxvi., p. 364. Dubreuilh, His- 
tologic, Lichen Plan des Muqueuses, Annales, 1906, s. iv., vii., pp. 123-129 (list 
of cases). Vomer, Ombilication dans le Lichen ruber plan de la muqueuse, 
Zeitschr., 1906, xii., p. 107; Annales, 1907, s. iv., viii., p. 145. 



336 HYPEEMMIAS AND INFLAMMATIONS. 

a mass of lymphoid cells with a few polynuclear leucocytes compose 
the infiltration. The blood-vessels are relatively " respected" and the 
usual elongated rete-pegs pass below, at times branching, into the 
interpapillary hyperplastic mass. 

LICHENIFICATION. 

This term was applied first by Brocq and Jacquet to areas, usu- 
ally limited and circumscribed, in which the skin is reddened, infil- 
trated, and more or less covered with fine scales, but in which the 
marked feature is an intensifying of the normal lines and furrows 
of the skin, as a result of which the patch is broken into small, more 
or less elevated, triangles, squares, or quadrilaterals which closely 
resemble the flat, angular papules of lichen planus. This condition 
of lichenification is seen in the subsiding stages of various forms of 
dermatitis, and also in areas that have been subjected to mild but 
long-continued scratching or other external irritation. The disorder 
is seen most frequently about the flexures of the joints, the fork of 
the thighs, and the back of the neck, but may appear on any part of 
the body, and is sometimes quite extensive. The condition usually 
disappears promptly under protective and antipruritic treatment, 
but shows a marked tendency to recur. 1 

IMPETIGO. 

(Lat., impetere, to rush upon.) 
(Ger., Eiterflechte ; Fr., Impetigo, Dartre iiumide.) 

The various forms of impetigo described by older writers are now 
otherwise classified, leaving impetigo contagiosa as the only form of 
the disease having this title. 

Impetigo Contagiosa. — (Porrigo Larvalis, Porrigo Contagiosa, 
Pemphigus Acutus Contagiosus Adultorum (Pontoppidan).) This 
is one of the common forms of skin-disease. The first lesions 
are one or a few discrete vesicles or pustules which are trans- 
formed so rapidly that they are not usually seen before crusting. 
In most cases the lesions are located on the face and ears and in 
children on the scalp, sometimes on the neck and hands; rarely on 
other parts of the body. 

The lesions present are yellowish, gummy-like crusts, which 
through admixture with blood may be blackish. These crusts seem 
to be pasted on the skin; they extend somewhat beyond the borders 
of the surface they cover; their edges are sometimes slightly curled 
upward. Underneath the crusts there is a superficial erosion having 

1 For full discussion of the subject, see Brocq 's chapter on "lies Lichens," La 
Pratique Permatologique, t, iii., p. 1J9, 



IMPETIGO. 



337 



a distinct outline. Erosions free from crusts, presenting simply a 
weeping surface occur with the other lesions. The lesions not over 
pea-sized in the beginning, attain the size of a penny. There is 
sometimes a sprinkling of bright red papules. In a given case lesions 
are seen in all stages and these may become confluent. In children 
pustular lesions of the fingers are not uncommonly associated with 
impetigo of the face; and stomatitis is observed from time to time. 
Dark erythematous areas remain after the disease has disappeared, 
gradually fading without the production of scars. Permanent scars 
in some cases are left by impetigo contagiosa of the scalp. 

Fig. 63. 




Staphylococcia, superficial type. 



Impetigo Contagiosa G-yrata. — This is a clinical variety of the dis- 
ease in which the lesions spread in a serpiginous manner so as to 
form circles. 

Impetigo Contagiosa Bullosa. — In adults this form of the disease is 
observed only. after vaccination, but in infancy it is not uncommon, 

22 



338 



HYPEREMIAS AND INFLAMMATIONS. 



The eruption described as Pemphigus Neonatorum is one form of 
this affection. 

Symptoms. — The disease occurs largely in the summer months. 
The eruption lupins as one or two bullae which are not surrounded 
by areola? of redness. They rupture quickly, leaving coin-sized, 
sharply defined areas of excoriated surface, which multiply rapidly 

Fig. 64. 




Impetigo contagiosa 



until the entire part affected is covered with denuded areas to the 
borders of which shreds of epidermis are attached. In hospitals this 
disease spreads from one infant to another with great rapidity and in 
spite of all precautions. 

The several clinical pictures differ on account of the greater or 
lesser diffusion of the contagious elements in each case; for example, 
there may be a few isolated pea-sized and larger vesico-pustules on a 
single hand ; or many may be clustered about the mouth and lips ; or 
dense greenish crusts may succeed such lesions over occiput or scalp ; 
or there may be much larger pustulo-bullous elements over the legs, 
torn, scratched, and thickly covered with pustular or hemorrhagic 
incrustations. In rare instances circinate, annular, gyrate, ser- 
piginous, herpetic, variolaform, and even pustulo-crustaceous lesions 
have been observed. The disorder is not often seen in private prac- 



IMPETIGO. 339 

tice, but in public patients it occurs among the cachectic, the filthy, 
and the neglected. The several types of impetigo described as staphy- 
logenes, streptogenes, circinata, etc., have no distinction of symptoms. 

Etiology. — The disease is a pus infection the result of the trans- 
mission to the skin through the medium of finger-nail-filth of a 
mixed infection of streptococci and staphylococci; often the one is 
grafted upon the other. The peculiarities of the former are the short- 
ness of their chains, the slightness of their incurvations, their failure 
to interlace, and the irregular form of the elements of which the 
chains are composed. For these reasons an attempt has been made, 
without result thus far, to disassociate the germs of this disease from 
those found in the pus of other affections. 

In some cases the irritation is set up by the encroachments of 
the trichophyton. In other cases there are pediculi of the occipital 
region, and the scratching set up in consequence of attacks of lice 
furnishes the opportunity for infection with staphylococci. 

In children the disease is often associated with pyogenic nasal 
infection. It may be conveyed from one child to another and hence is 
frequently contracted in schools. Women contract the disease from 
children, while in men the most frequent source of the infection is the 
barber shop. Sometimes it develops upon areas previously in a mor- 
bid condition. 

The eruption often occurs during convalescence from a more or 
less actively -contagious disease. The antecedence of some fever in 
many cases is admitted by all observers. Duhring and Fox have 
seen it follow vaccinia, and the former admits that some connection 
between the two seems probable. It may occur typically in a series 
of children, each of whom is convalescent from varicella. 

Pathology. — The lesions have been examined microscopically by 
Bockhart and others, who have thus been able to establish clearly the 
coccogenous origin of the disorder. Plainly, each lesion is but a dis- 
tinctly circumscribed and superficial pea- to bean-sized abscess, situ- 
ated between the intact corneous and the prickle-layers of the skin. 
Balzer and Griffon 1 agree with Thibierge and Bezancon in asserting 
that almost without exception the lesions of impetigo and ecthyma 
early contain streptococci and no staphylococci. In some cases, how- 
ever, the staphylococcus pyogenes aureus and albus are present. 2 
Darier and other French dermatologists describe an impetigo strepto- 
coccogenata circinata, in which the lesions closely resemble those of 
herpes iris, and in which the streptococcus only is found. Leroux 
and others, recognizing the fact that many microorganisms similar in 
external appearance, have decidedly different potentialities, have sug- 
gested that the streptococci responsible for the several clinical pictures 
of impetigo may differ in effect. Sabouraud 3 has demonstrated that 
the streptococcus usually present is disguised by the rapidity of devel- 
opment of the staphylococci commonly recognized. 

x La Presse med., 1897, lix., p. 130. 

2 Cf. Engman, J. C. D., 1901, xix., p. 180. 

"Annales, 1900, s. iv., i., pp. 62 and 320 (report of his researches and review 
of literature). 



340 HYPEREMIAS AND INFLAMMATIONS. 

In Unna's differential diagnosis of the impetigo- and eczema- 
pustule stress is laid upon the sero-purulent character of the contents 
of the latter, the dissemination of cocci throughout the lesion, the 
softening of the corneous layer in places, and the occurrence of moro- 
cocci free and within the leucocytes. In impetigo the staphylococci 
are clustered, are extracellular, are relatively small, and are collected 
beneath the intact roof -wall of the lesion. 

Dewevre 1 reports a number of successful inoculations and auto- 
inoculations practised with the contents of the vesico-pustule, with 
finely powdered impetiginous crusts, and with the products of scrap- 
ing the subjacent erosion. In 1884 I succeeded in producing an 
almost typical vesico-pustule upon the left forearm by inoculation 
(all due precautions being observed) with the moistened debris of 
crusts. This inoculation was done in the clinic, the crusts being 
taken from typical lesions upon the face of a young girl inoculated 
while under observation from the lesions of exactly similar character 
on the face of her twin sister. The lesions on the forearm produced 
a characteristic crust which in seven days was also used for inocula- 
tion of two students then present at the clinic, in one of whom there 
was no result, and in the other an abortive lesion. 

The disease is contagious, and its lesions inoenlable and auto- 
inoculable. 

Diagnosis. — To establish the identity of this affection it is neces- 
sary to define its exact differences from eczema pustulosum. These 
differences are : first, the absence of infiltration of the tissues affected ; 
second, the absence of itching; third, the failure of the lesions to form 
patches ; fourth, the isolation and wide separation from one another 
of lesions distinctly pustular; fifth, the large development and rather 
persistent character of the pustules ; sixth, the evident termination of 
the disease, which does not, as in many cases of eczema, progress 
to form a freely discharging and crusting surface, the pustular being 
but the initial stage of a distinct morbid process. Manifestly, how- 
ever, an impetigo of the sort described is not incompatible with an 
eczema which is often originated by less irritating causes. 

In ecthyma the pustules are in appearance much more formidable 
than those of impetigo in consequence of their size, depth, inflamma- 
tory base, areola, flat, hard and bulky crust, and erosive action upon the 
skin. 

In varicella the lesions are small, much more widely distributed 
over the body, and are vesicular only, rarely bullous. In pemphigus 
and herpes iris the seat, character, and period of evolution of the 
Lesions suffice to establish the diagnosis. 

Treatment. — Individual pustules are to be opened with an aseptic 
needle; the purulent contents gently removed by washing with 
borated water ; and the floor smeared with any mild ointment, such as 
5 grains to % scruple (0.33-0.66) of ammoniated mercury to the 
ounce (30.) of cold-cream salve, or bismuth subnitrate ^ drachm 
1 Arch, de Med. et de Pharm. mil., 1885, vi., p. 210. 



ECTHYMA. 341 

(2.) to the ounce (30.), of benzoated zinc-salve. Van Harlingen 
recommends the application of a salve on bits of muslin, covering 
the whole with waxed paper. A dusting-powder containing calomel 
may be substituted for the salve or be employed afterward. The 
disease tends to spontaneous recovery if the lesions be not irritated. 
When they are situated within reach of a child's tongue which is 
constantly thrust out to moisten them, they may linger obstinately and 
require protection by flexile collodion. 

ECTHYMA. 

(Gr., enOv/Lta, a pustule; ek6vu, I burn out.) 

(Ger., Ekthyma, Eitekblase.) 

The term " ecthyma," like several of the titles of chapters imme- 
diately preceding, no longer points to a distinct disease. In infants 
it affects the buttocks, in adult life the lower extremities. It occurs 
mostly in those suffering from circulatory and oedematous disturb- 
ances of the lower extremities and cachexia produced by alcohol, 
tuberculosis, and other debilitating diseases. It represents a toler- 
ably definite group of symptoms readily separable clinically from 
other affections produced by different causes. The most common 
cause is infection of the skin of the lower extremities with pus-cocci 
after scratching; then follow traumatisms, primary and secondary, 
associated with pediculi of the body (pediculus vestimenti), and com- 
binations of these with bedbug-bites ; general filthiness of the person 
and clothing of body and bed. The term ecthyma is, however, not to 
be discarded merely because of these composite etiological factors, as 
the picture produced in the skin is characteristic. 

The eruption begins as a pustule, at the base of which cellulitis 
develops ; destruction of tissue follows, producing an ulcer, pea to small- 
coin size. This is the chief clinical feature of the disease and the 
only lesion which the ancients called ecthyma. The ulcer of ecthyma 
is crater-like, and is surrounded by a bluish collar which elevates the 
tissue and causes the ulcer, though quite shallow, to appear deep. In 
many cases the ulcer is covered by a dark-colored, thick, rough, ad- 
herent crust. 

The deeper lesions are followed by pigmentation and persistent 
punctate or larger cicatrices. The entire course of the disease occu- 
pies about two weeks. The subjective phenomena are a sense of heat, 
burning, pain, and soreness. There may be accompanying lymphan- 
gitis or adenopathy. 

Etiology. — The pyogenic cocci (in particular streptococci) are 
the efficient causes of most of the lesions; practically the agents 
capable of producing eczema and dermatitis (traumatism, heat, 
scratching, parasites, etc.) either effectively operate or influence to 
a morbid degree the subjects of other diseases, such as anaemia, 
asthenia, struma, variola-convalescence, and menstrual disorders. 



342 HYPEB&MIAS AND INFLAMMATIONS. 

Filth and neglect are most common aggravations; in other words, 
that circumscribed cutaneous ulcer will be the angrier and the deeper 
which occurs in the victim of any depressing disease whose skin is 
scratched with nails begrimed with dirt, and is covered with the 
products of the excretory processes. The pus thus produced is in 
various degrees inoculable and auto-inoculable, as is the product of 
many inflammatory processes of similar grade. 

Pathology. — In many cases of ecthyma there has been demon- 
strated a streptococcic infection of the skin, usually with but few 
chains of micro-organisms visible on bacteriological examination. 
The pustule of the disease differs from the pustule of eczema or the 
pustule of impetigo in the severity of the exudative process by which 
it is produced, and in its limitation to the exact seat of external irrita- 
tion. By the extension of that process to the corium there is an actual 
loss of some of the elements constituting the papillary layer, the result 
often being a cicatrix which contracts as it grows older, and which is, 
in milder cases, finally barely visible as a minute cicatriform punc- 
tum. One who frequently examines the skin of the entire body with 
care can usually detect the ancient sites of these lesions by their in- 
delible though insignificant relics. 

According to Unna, the ecthyma-pustule, as distinguished from 
that of impetigo, is less an epidermal abscess than a result of epider- 
mal inflammation, fibrinous at the centre and exceedingly oedematous 
at the periphery. The crust contains fibrin and epidermal layers. 

Sabouraud points out that the original streptococcic infection is 
often succeeded by a secondary microbian involvement whereby the 
staphylococci present are enabled to produce the peripheral lesions 
of impetigo, furunculosis, etc. 

Diagnosis. — Ecthyma is liable to be confounded with the other 
pustule-producing exudative affections, but as the distinction between 
them is largely artificial and based upon the severity of the inflamma- 
tory process, there is small danger in consequence. Kaposi expresses 
the truth in his suggestion that there can be but little objection to the 
employment of the term ecthyma when it is desired to characterize 
precisely the pustular grade of any cutaneous inflammation at a given 
time. The pustules of variola are " ecthymaform," and many of 
those seen in syphilis exhibit similar characters; but the history of 
the general affection should throw light upon the identity of the cu- 
taneous disease. In syphilis, moreover, the ulceration at the base 
of the lesion exhibits the pronounced features of the syphilitic ulcer 
in its secretion, floor, edges, base, crust, and career. The crust, in 
particular, of the flat pustular syphiloderm has the rupioid conical 
appearance which suggests the shell of the oyster, and the underly- 
ing ulcer is larger and deeper than in ecthyma. In the furuncle 
there is usually a central core; in impetigo the pustules are not 
deep-seated, and there is no ulceration at the base; the crust is 
superficial, yellowish, firmly adherent, and the lesions are more 
numerous. 



DERMATITIS VEGETANS. 343 

Treatment. — The general treatment of patients affected with 
ecthyma is a matter of importance. A proper regulation of the 
food and hygienic surroundings is not to be neglected. Tonics are 
frequently indispensable, including iron, quinine, and strychnine. 
The destruction of any pediculi and the cleansing of the skin with 
soap and water will often be sufficient to effect a great change. This 
fact is well illustrated in hospital practice, where young patients 
rapidly improve after a bath, followed by inunction with vaselin, 
and a few substantial meals of a nutritious character. When the 
lesions are abundant the treatment is in general that of pustular 
eczema. Crusts are to be removed after soakings with oil or fat ; 
and the floors of the former pustules, after washing with car- 
bolated water, should be dressed with an ointment containing from 
10 to 15 grains (0.66-1.) of mercuric ammonio-chloride to the ounce 
(30.) of lard. If the minute basal ulcers are sluggish, they may, 
after careful cleansing, be touched with a small swab that has been 
dipped in a 0.5 per cent, formalin solution or in a solution of mer- 
curic chloride in tincture of benzoin, 1 grain (0.066) to the ounce 
(30.). Carbolic or boric acid or iodoform may be employed for the 
same purpose. For the salve mentioned above may be substituted 
one containing 10 grains (0.66) of calomel, or -J drachm (2.) of 
bismuth subnitrate to the ounce of salve-basis. 



DERMATITIS VEGETANS. 

Under the title of Pyodermite vegetante, Hallopeau 1 describes 
five cases of a disease affecting chiefly the scalp, axillae, genitals, 
groins, lips, and the mucous membrane of the mouth, in which there 
appear miliary pustules which soon are surrounded by a hypersemic 
base. The pustules appear in successive groups, coalesce, and the 
area thus formed becomes covered with crusts beneath which form 
more or less elevated vegetating surfaces. These patches may in- 
crease by peripheral extension, but more commonly by the forma- 
tion of new pustules at the border. On the mucous membranes 
rupture of the pustules is followed frequently by superficial ulcers. 
The disease yields readily to antiseptic treatment, leaving only a pig- 
mentation which gradually disappears. Hallopeau considered the 
disorder a type of local infection spreading by auto-inoculation. 
Similar cases have been reported under the title of Dermatitis vege- 
tans by TIartzell 2 and Jamieson. 3 Wende 4 has reported two sim- 
ilar cases occurring in children during the course of eczema, in both of 
which papulo-pustules were followed by crusts and vegetations, chiefly 
on the scalp and face. He collates 12 other cases from literature, 
5 in infants and 1 in adults. In all there was the same type of pap- 

1 Archiv, 1898, xliii., p. 289; and xlv., p. 323. 

2 J. C. D., 1901, xix., p. 465 (with histology). 

3 B. J. D., 1902, xiv., p. 407. 

4 J. C. D., 1902, xx., p. 58. 



344 HYPEREMIAS AND INFLAMMATIONS. 

ulo-pustules appearing in groups, the resolution of old lesions with 
the appearance of new, the production of vegetations, and the disap- 
pearance of the disease under antiseptic treatment. The disorder 
is probably the result of an infection and not directly related to 
the eczema which preceded the disease in 7(5 children and 2 adults) 
of the cases. The disorder is distinguished easily from pemphigus 
vegetans, which it resembles clinically, by the readiness with which it 
yields to antiseptic treatment, and by its failure to affect the general 
health of the patient. 

CONGLOMERATIVE PUSTULAR PERIFOLLICULITIS. 

Leloir 1 gave this name to an eruption which he described as ap- 
pearing on the backs of the hands and buttocks and occasionally on 
other parts of the body. 

The disease begins by the appearance of a round or oval, somewhat 
elevated, reddened or purplish plaque, with definite outlines. The 
plaque may be no larger than a dime, or it may be of the size of a 
large coin or larger, and may be elevated a quarter of an inch above 
the general level of the skin. Its surface is smooth or mammillated 
and is perforated by numerous follicular openings from which pus or 
dried plugs resembling comedones may be expressed. The openings 
of some of the follicles may be covered by unruptured pustules. 
Later, the patch becomes more phlegmonous, fluctuation can be de- 
tected, the follicles are more patulous, and pus in large quantity can 
be expressed. The whole then has much the appearance of a kerion of 
the scalp or of a flat carbuncle. 

There is usually but one such plaque, though there may be two or 
three, rarely more. Subjective sensations are slight, though there is 
usually some itching and burning. There is no systemic disturbance. 
The disease runs a rapid course, requiring about a week in which to 
develop, after which it remains stationary for a week or two, and then 
disappears under appropriate treatment in from ten to fifteen days. 
More or less deep pigmentation remains some time after the lesions 
heal, but there is no ulceration and in the few cases in which scars are 
lcl'l these are usually very superficial. 

FOLLICULITIS AND PERIFOLLICULITIS. 

Quinquaud and Pallier 2 describe a follicular disease which is 
chronic, becomes papillomatous, and is very stubborn under treat- 
ment. Besnier and Doyon 3 enumerate five varieties of the disease, 
including two pseudo-ulcerative, serpiginous, and virulent forms 
which resemble anatomical tubercle. 

Etiology. — Those disorders are probably due to contagion, and are 

1 Annates, 1884, s. ii., v., p. 437 (with plates). 

2 Des perifollicultes suppurfies agininees en placards." These tie Paris, 1889. 

"Kaposi: Besnier-Dc-yon, vol. i., p. 795. 



FUEUNCULOSIS. 345 

seen most frequently in those who work among horses and other 
animals. 

Pathology. — The process is an inflammation of the follicles, peri- 
follicular tissues, and> sebaceous glands. Leloir found several forms 
of micrococci and zooglcea in the pus, but he failed to reproduce the 
disease by inoculation-experiments. Quinquaud and Pallier believe 
the active agent to be staphylococcus pyogenes albus, which acci- 
dentally obtains entrance to the follicles and glands. Sabouraud 
found in several cases a large-spored trichophyton. 

Treatment. — The treatment is purely local. In the usual milder 
forms daily evacuation of pus, hot boric-acid fomentations, or fre- 
quent hot bathing, with antiseptic dressings, constitute the only treat- 
ment necessary. In the stubborn forms stimulating treatment by 
means of strong solutions of silver nitrate or of carbolic acid, or by 
means of the actual cautery, may be indicated. Occasionally it will 
be necessary to remove the growth with a curette. 

FURUNCULUS. 

(Lat., furunculus, a petty knave.) 

(Furuncle, Boils. Ft., Furoncle, Clou; Ger., Furunkel, 
Blutgeschwur, Eiterbeule, Eitergeschwur.) 

A furuncle is a staphylococcus infection of a hair-follicle produc- 
ing a painful cellulitis which terminates in the death of tissue and 
the expulsion of a necrotic plug. Furunculosis is the succession of 
furuncles. 

Symptoms. — Furuncles commonly begin as tender and painful 
indurations in the skin or its subjacent tissues, the summit of each 
nodule soon becoming visible in the epidermis as a reddish punctum. 
A furuncle is the result of an active inflammatory process, limited to 
a definite area, and of greatest intensity at the centre of the involved 
mass. This centre is often represented by a hair-follicle, the pustule 
that forms subsequently being perforated by a hair. 

More or less rapidly thereafter these symptoms are succeeded by 
increased redness, heat, and tumefaction, the latter producing a nut- 
or egg-sized tuberosity, well projected from the surface or fairly im- 
bedded within or beneath the derma. A yellowish point in the centre 
of the erythematous swelling soon announces the occurrence of suppu- 
ration. When accidentally or artificially opened at this summit exit 
is given to thick yellowish pus with which blood may be commingled 
from the traumatism of neighboring capillaries. The small abscess 
may then, after discharging its purulent contents for a few days, 
gradually close by granulation, or may also expel from its cavity a 
tenacious, pus-covered, yellowish-green slough, known as the "core." 
This evacuation is usually followed by relief of the tense and throbbing 
pain which is the well-known subjective characteristic of the furuncle. 



346 HYPEE&MIAS AND INFLAMMATIONS. 

The length of time requisite for the completion of this process 
varies with the extent of tissue involved, from a few days to several 
weeks. Boils may occur in any part of the body, but are most com- 
mon about the face, the auricular region, the neck, the armpits, the 
anogenital surfaces, the hips, the buttocks, the breast, and the ex- 
tremities. They may occur as single or as multiple lesions, or they 
may succeed each other in crops, especially about the buttocks, trunk, 
and thighs, for a period of several months. The disease of the skin 
may produce a constitutional effect manifested in pyrexia, which is 
usually encountered only in individuals of irritable constitution when 
the furuncles are few and short-lived. There is also a decided chloro- 
anasmia due to the pain, fever, purulent drain, irritability of nervous 
centres, inappetence, and consequent perversion of nutrition. 

The sequels of boils are maculations of a violaceous tint, often per- 
ceptible in the skin for weeks and even months after their disappear- 
ance ; and pinhead- to penny-sized cicatrices which are permanent. 

Etiology. — The microbe which is the immediate cause of boils is 
usually, if not always, the Staphylococcus pyogenes aureus, 1 though 
other pus-producing cocci also are found in the lesions. The remote 
cause is often exceedingly obscure. It is true that boils are encoun- 
tered in typical subjects of diabetes, of the exanthemata, and of "hos- 
pitalism," in whom anaemia, asthenia, marasmus, malnutrition, and 
exhaustion resulting from excesses, from grave general disease, from 
low fevers, and from nervous strain, play a prominent part. But 
the reverse is also true. 

Scratching, eczema, scabies, other cutaneous diseases, lice, and ex- 
ternal irritants of various sorts are responsible for many boils, espe- 
cially those that are few and not followed by similar lesions. When, 
however, such sequence occurs it should not be forgotten that the pus 
is auto-inoculable, and that furuncles, if sufficiently numerous and 
large, are capable of disturbing the general economy. A collar-button 
at the back of the neck ; the edges of an unyielding corset in one un- 
accustomed to it; a hard bench; a saddle-tree; a velvet coat-collar 
sheltering the germs responsible for a previous attack; and many 
similar articles may be the exciting cause of furuncles. 

Account should always be had, in cases of persistent furunculosis, 
of externally operating poisons. In this category must be included 
sewer-gas emanations, arsenical wall-papers, and the poisons handled 
in the trades, e. g., by dyers, lead-manufacturers, etc. 

Lastly, it is exceedingly common for patients thus affected to ap- 
ply to practitioners for remedies intended to " purify the blood " ; 
and, inasmuch as potassium iodide is often prescribed in response to 
this demand, the original trouble is thus enhanced to a manifold ex- 
tent. Many cases of furunculosis are instances of boils resulting 
originally from external irritation, that have greatly multiplied and 
finally profoundly affected the system under the impulse of the so- 
called "blood-purifying" process. 

' Cf. Gilchrist, Johns Hopkins Hosp. Keports, 1903, xiv. 



FUEUNCULUS. 347 

Pathology. — According to Unna, most furuncles begin with an 
impetiginous lesion due to the inoculation of the pilo-sebaceous fol- 
licle with pus-cocci, the organism being, in the majority if not all 
instances, Staphylococcus pyogenes aureus. The cocci penetrate 
deeply into the follicle, into ramifications of the sebaceous gland, and 
into the surrounding tissue. An abscess surrounding the follicle thus 
is produced which undergoes a necrosis en masse, producing the char- 
acteristic central core or slough. It is probable that in some instances 
the cocci are carried along the lymph-vessels to form abscesses about 
the neighboring follicles and glands. The lanugo hair-follicles are 
affected much more frequently than those of the stronger hairs. 

Diagnosis. — Boils are to be distinguished from carbuncles by the 
aggravated symptoms of the latter. Circumscribed furuncular ab- 
scesses of the groins and the axillae are not to be confounded with 
suppurating, sympathetic, or virulent buboes of these regions, associ- 
ated with genital or extragenital contagious venereal sores. Errors 
of this sort have been made. Furuncles of the anal and genital 
regions in point of diagnosis may be significant of surgical affections 
of the neighboring parts (perineal, periprostatic, peri-urethral, aud 
scrotal abscesses in men; suppuration of the vulvo-vaginal gland in 
women, etc.). 

Treatment. — The debilitated constitution of many patients af- 
fected with boils indicates clearly the need of a tonic regimen, includ- 
ing the administration of iron, quinine, and strychnine, the mineral 
acids, and, contrary to the generally accepted opinion of the laity, a 
generous diet of milk, cream, eggs, and fresh meats. To these articles 
of diet wines and malt liquors may at times be added with advantage. 
Change of climate, of diet, of cooks, and of the habits of life is most 
serviceable in cases of prolonged furunculosis. The mineral waters 
at some health resorts prove especially valuable for the debility which 
often results from these disorders. The urine should always be ex- 
amined for sugar, albumin, and an excess of urates. The internal 
remedies which possess reputation in this complaint are arsenic, 
sulphur and the sodic sulphites, the alkalies, tar, fresh yeast in table- 
spoonful doses, phosphorus, and the syrup of the hypophosphites of 
calcium, iron, sodium, and potassium. 

Calcium sulphide, which was once more highly esteemed than any 
other of the internal remedies named, is given in doses of Yw to % 
grain (0.0066-0.0133) every three or four hours. It is doubtful 
whether the drug exerts any influence whatever upon furuncles. In 
lithsemia potassium acetate or citrate is given in large dilution, or the 
liquor potassse ; in gouty states colchicum, salol, and the alkalies, in- 
cluding the sodic salicylate. No one of these articles, however, may 
be described as an efficient and certain remedy for the complaint ; many 
cases will progress without hindrance from any or all of them. Fresh 
brewer's yeast, recommended by Lowenberg, Crocker, Brocq, 1 Des- 
'La Presse med., 1899, lxi., p. 45 (with bibliography). 



gr. xv-xxx; 


1-2 


5jss; 


6 


f5J; 


30 


*3 v ; 


150 



348 HTPEIi^MIAS AND INFLAMMATIONS. 

fosses, 1 and others, is sometimes of service. A tablespoonful or less 
may be given three times a day. 

Attempts in the direction of aborting a furuncle by the topical 
application of the stronger alkalies (aqua ammonias) or acids, caustics, 
cautery, ice, iodine, or carbolic acid, or premature complete excision 
with the scalpel, occasionally succeed, but often they fail. Boils may 
be aborted at times by the injection beneath the lesions of from 3 to 6 
drops of a 3 per cent, solution of carbolic acid. 

The objects of local treatment are to reduce the inflammatory 
process, allow the free escape of pus, and to prevent infection of other 
follicles in the neighborhood. The surface of the boil and the skin in 
the neighborhood should be kept thoroughly clean by frequent use of 
hot water and green soap, and the application at least twice daily of 
some simple antiseptic solution, such as 50 per cent, alcohol, 1 per 
cent, carbolic acid lotion, or weak bichloride solution. Stelwagon 2 
recommends for the purpose : 

5 Resorcin., 
Acidi boriei, 
Alcoholis, 
AquiE dest., 

Before rupture of the furuncle it may be protected by means of an 
ointment or paste containing ichthyol, 1 to 2 drachms (4.-8.) to the 
ounce (30.), or, by protecting the surrounding skin with such an oint- 
ment or paste, hot antiseptic applications may be applied to the lesion 
itself. A convenient and effective dressing at this stage is found in 
the official cataplasma kaolini, containing sterilized clay, glycerin, and 
a mild antiseptic. Such a dressing may be continued even after 
the opening of the furuncle if care be taken to permit free discharge 
of the pus. 

The furuncle should be opened freely with a clean incision when 
pus has formed, but not before. Violent squeezing of the furuncle to 
separate its slough or evacuate the contents should never be practiced, 
though it is permissible in some instances to scrape out the contents 
with a curette. The cavity should be cleansed thoroughly at least 
twice a day with hydrogen peroxide or with solution of carbolic acid 
or mercuric chloride, and packed with iodoform, boric acid, aristol, 
<>r other powder. In place of these powders, carbolic acid in crystal 
or in strong solution may be employed. 

Prognosis. — Eventually the worst cases are relieved when unac- 
companied by systemic or visceral disorders, and when the circum- 
stances of the sufferer permit him to pursue the most advantageous 
course (travel, diet, abstraction from business, etc.). The resulting 
cicatrices depend upon the severity of the process. Often they are 
small and in the course of years become scarcely distinguishable; in 
exceptional eases they are large, persistent, and disfiguring. Lympius 3 

1 Ibid., 1892. liv., p. 653. 

' Diseases of the Skin, 3d ed., p. 382. 

3 Deut. med. Wchnschrft., 1899, xxv., p. 474. 



CARBUNCULUS. 349 

calls attention to the serious and even fatal complications (purulent 
arthritis, meningitis, thrombosis of frontal veins, septic infarct in 
lung) which may complicate furunculosis of the face, owing to the 
vascularity of the region. 

CARBUNCULUS. 

(Lat., carlo, a live coal.) 

(Anthrax Simplex, Carbuncle. Ger., Karbunkel, Brand- 
schwaee; Fr., Anthrax.) 

A carbuncle is an acute, flattish, circumscribed, cutaneous and sub- 
cutaneous abscess, usually larger than a furuncle, that is due to the 
presence of staphylococci, and is characterized by dense induration 
and sloughing, terminating in favorable cases by the production of a 
persistent cicatrix. 

Symptoms. — Carbuncles are often preceded by malaise, chill, and 
pyrexia of severe grades. There is commonly a burning pain at the 
site of the lesion. In cases in which the carbuncle is formidable and 
seated upon or near the head alarming symptoms of prostration, stu- 
por, somnolence, and even coma, may be noted. With and without 
these concomitants a dense, dull-red, indurated, and painful phlegmon 
soon appears, varying in size from that of a small hen's-egg to that of 
an orange and even much larger, involving not only the skin, but also 
the tissues beneath. Suppuration finally occurs, but the pus is not 
confined to a single space; it undermines the integument and often 
through several apertures leaks out indolently to the free surface. 
The fenestrated or cribriform appearance of the skin covering the 
carbuncle constitutes in this stage one of its most striking features. 
Through these apertures may be distinguished the whitish or yellow- 
ish pus-soaked sloughs or portions of a single slough, which can at 
times be extracted through the orifice. Often the entire mass sepa- 
rates in a single slough involving the skin and subcutaneous tissues, 
leaving a crateriform ulcer of formidable size, which in favorable 
cases proceeds to heal by granulation. The resulting cicatrix is at 
first of a deep violaceous tint and later becomes blanched. It is 
indelible. 

There is commonly one lesion ; at times several simultaneously or 
successively develop. The sites of election are the neck, upper chest, 
buttock, and lower extremities. 

The fever which usually accompanies this process may be mild or 
be severe, or, more commonly in dangerous cases, be of a typhoid char- 
acter. It results unquestionably from sepsis due to unliberated pus 
and necrotic tissue, and is naturally most grave in its consequences 
in patients weakened by previous asthenic disorders. Under these 
unfavorable circumstances the carbuncle may spread at the periphery, 
enclosing islands of necrotic tissue and ill-conditioned pus separated 
by bridges of empurpled, infiltrated, and yielding skin. 

The characteristic lesions of this disease most often appear on the 



350 HYPEREMIAS AND INFLAMMATIONS. 

back of the neck, the back of the trunk, and the lateral aspect of the 
hips and thighs, usually in a single development, though occasionally 
two or even three carbuncles of small or of medium size may coexist. 
The reason for their appearance in the localities named is clear. It is 
here that the skin is most thick and resistant, and, as a consequence, 
purulent foci when formed are covered in by the most voluminous 
layers of the connective tissue of the corium. 

Etiology. — Anthrax simplex is produced by the obscure causes 
to which reference has already been made as probably effective in the 
production of boils. Carbuncles and boils may coexist; or the one 
lesion may follow the other; and there may occur intermediate forms 
assignable to either class. The disease is encountered more often in 
men than in women, and in later than in earlier life, simply because 
the tissues constituting its sites of preference offer in these individuals 
and at these ages a greater resistance to the exit of pus. The pus- 
cocci may sustain an etiological or purely an accidental relation to the 
lesion. Carbuncle is at times an epiphenomenon in cachexia, dia- 
betes, albuminuria, syphilis, pemphigus, and exfoliative dermatitis. 

Pathology. — The pathological anatomy of carbuncle has been well 
described by Warren, 1 whose observations conclusively show that the 
inflammatory process here is that seen in the simplest pustule. The 
special symptoms of carbuncle are due solely to the formation of the 
phlegmon beneath the dense and extremely thick masses of fibrous 
tissue found in the back " for the protection of that comparatively 
defenceless portion of the body." The cell-elements, multiplying with 
the intensity of the inflammatory process in the subcutaneous adipose 
tissue, pass upward along the fat-columns, crowd between these and 
push along the horizontal clefts branching from either side, infiltrate 
the derma, pass along the edges of the hair-follicles, fill the papillae 
until the latter "balloon" with pus, ooze to the surface through the 
cribriform aperture in the undermined epidermis, and macerate the 
bundles of fibrous tissue relatively intact that constitute the un de- 
tached mass of sloughing tissue. 

The constitutional symptoms in carbuncle (pysemic, septicemic, 
or sympathetic) are due solely to pus-imprisonment. The pus-forma- 
tion is due to the presence of the staphylococcus pyogenes aureus and 
its toxine. Back of all (in the diabetic, the cachectic, etc.) lies the 
favorable soil for multiplication of the microorganism. 

Diagnosis. — It follows from what has preceded that carbuncle and 
furuncle differ solely in the depth of the starting-point of the phleg- 
mon, and the density and resisting power of the overlying tissue. The 
carbuncle is, therefore, flatter, denser, less rapidly developed, larger, 
less tender, and more painful ; opens by many rather than by one or 
two apertures ; and is followed by larger sloughs, ulcers, and cica- 
trices, and occasionally by fatal results. 

Treatment. — Crucial and other deep incisions in the local treat- 
ment of carbuncle are certainly inferior in results to the course advo- 
1 The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. 



CABBUNCULUS. 351 

cated by Wood 1 and Taylor, 2 whose method is employed in cases with 
complete success, namely : a saturated solution of pure carbolic acid is 
injected with a hypodermatic syringe through the several apertures in 
every direction into the sloughing tissues. When the orifices are not 
sufficiently numerous the point of the needle is thrust through the 
thinned integument at the summit of the swelling at several points. 
The pain is severe but short-lived ; the tissues are blanched, indurated, 
and destroyed; the slough in a few days is readily separated after 
division of its slender fibrous attachments ; and the ulcer rapidly con- 
tracts with the sequel of a smaller scar. It is necessary to use pure 
acid in saturated solution to prevent absorption of the injected fluid 
and the resulting toxic effects. 

Relief is afforded in many cases by hot borated lotions and fomen- 
tations with the requisite skill in the surgical dressing of the parts, by 
carbolated lotions, extraction of the slough wholly or in portions with 
the forceps, and the subsequent employment of boric acid, iodol, iodo- 
form, or aristol, or the paste recommended in the treatment of furun- 
cles. An excellent method of withdrawing the purulent and slough- 
ing contents of the carbuncle is to apply over it at the proper period 
an exhausted receiver, such as a common cupping-glass. 

Erasion of the entire abscess with a curette and subsequent anti- 
septic dressing is an accepted radical measure of relief for employ- 
ment in proper cases. 

The antiseptic treatment of a carbuncle, however, furnishes the 
best results as regards the comfort of the patient and limitation of the 
disease. By this treatment there is absolutely no surgical interfer- 
ence with the lesion beyond the incisions made for the evacuation of 
pus. Violent squeezing and manipulation of the carbuncle are inter- 
dicted ; it is freely powdered with boric acid, iodol, or iodoform ; and 
on it is laid soft felt cloth thickly spread with any emollient and anti- 
septic salve, such as the ordinary zinc-salve. Boric acid in powder or 
iodol, thickly dusted over the carbuncle and covered with antiseptic 
wool, will also be found a useful dressing. 

Internally calx sulphurata may be administered in full doses ; it 
has, however, a questionable effect in diminishing the pus-formation. 

Other constitutional treatment may be demanded in carbunculosis, 
including the liberal employment of tonics, a generous diet, a strict 
observance of the rules of hygiene, and stimulants when indicated. 
Pyrexic, septicemic, pysemic, and adynamic states require the special 
management of such complications, including cold sponging of the 
body-surface in fever, and the use of quinine, the mineral acids, and 
stimulants, with artificially applied heat in the algid condition. The 
urine should always be examined for sugar and albumin. 

Prognosis. — A serious issue need only be anticipated when the 
complications described above are grave in character or they occur in 
asthenic constitutions. 

1 Toledo Med. and Surg. Jour., December, 1880. v 

2 Australian Med. Gaz., December 1, 1881. 



352 HYPEREMIAS AND INFLAMMATIONS. 

PHLEGMONE DIFFUSA (CELLULITIS). 

(Gr., fXeyfiovrj, an inflamed tumor.) 

This is a suppurative inflammation of the subcutaneous tissue 
caused by a streptococcic infection. Frequently the infection en- 
ters through a discernible wound of the skin, but it may occur without 
previous lesion. 

Symptoms. — In severe cases the disease begins with a chill and 
elevation of temperature. Usually the first evidence of the disease 
is a stinging sensation at the point of infection, which develops so 
suddenly and so closely simulates the feeling produced by an insect 
bite that the patient insists that he has been stung. The physician 
should exercise due caution in accepting such statements. 

The lesion which first appears is a red nodule situated deeply in 
the derma or subcutaneous tissue. Movement of the subjacent mus- 
cles causes pain. The redness soon spreads until it involves an area 
the size of the palm of the hand and the original nodule assumes a 
bluish color, so that there is present a bluish nodule surrounded by 
an area of redness. The outer red area never presents a distinct out- 
line but blends gradually with the healthy skin. The reddened area 
is infiltrated, hard, pasty-like; and pits on pressure. The central 
nodule becomes capped with a vesicle, ruptures, and discharges pus 
and necrotic tissue much to the relief of the patient. Painful streaks 
of lymphangitis extend to the neighboring lymphatic glands. Where 
the skin becomes gangrenous (gangrenous phlegmon) the danger of 
sepsis is so great that immediate operation is the advisable procedure. 
Metastatic abscesses may develop. 

Treatment. — The lesion should first be treated with hot moist 
dressings. Where the fever continues and the inflammation spreads 
surgical interference is needed. The operation is not to be under- 
taken lightly. It is often necessary to open deeply between muscles. 
In some cases amputation is necessary to save life. 

ANTHRAX. 

(Gr., avdpa% , a live coal.) 

(Malignant Pustule, Splenic Fever Carbuncle. Fr., Pustule 

MALIGNE, OhARBOH \ (iCr., MlLZBRANI), MlLZBRANl) KaRBUNKEL.) 

Anthrax maligna is a carbuncular lesion resulting from infection 
of the skin or other organ of the body with a virus containing the 
anthrax-bacillus, furnished by an animal infected with splenic fever. 

This form of the disease; in man, fortunately rare of occurrence, 
results from external inoculation and excepting a few cases of acciden- 
tal post-mortem inoculations and by the prick of a hypodermic needle 
(See) is derived from animal products such as wool and hair or 
from animals affected with the specific malady variously termed 
" anthrax," " charbon," " splenic fever," " splenic apoplexy," or 



AN TEE AX. 353 

" Texas fever." After inoculation with the disease from an infected 
animal the human subject may (a) perish from systemic poisoning 
wholly septicaemic in character with few external symptoms; or (&) 
when life is sufficiently prolonged, may suffer from visceral symp- 
toms, and develop subcutaneous tumors ; or (c) may exhibit the symp- 
toms of the disease now under consideration. 

Symptoms. — In from twelve hours to three days after inocula- 
tion ' a painless, somewhat pruritic macule, resembling a flea-bite, 
first is manifested, usually upon the dorsum or other part of the 
hands or the face, to which the virus has had access. The macule is 
followed in from twelve to fifteen hours by an inflammatory and 
pruritic papule, which is transformed rapidly into a flaccid bleb 
filled with a bloody serum. Usually the patient ruptures the bleb, 
exposing the base to view. At this point, the third or fourth day 
of the disease, the cutaneous lesion is fully developed. It consists 
of a plaque, the center of which presents a yellowish or blackish colored 
eschar surrounded by a collar of redness, studded with a few pus- 
tules. On palpation the plaque is found to be of cartilaginous 
hardness, extending deeply into the subcutaneous tissue and gradually 
fading into the surrounding tissue. Associated with this lesion is an 
extensive oedema involving an entire arm, the trunk, or face according 
to the location of the plaque. An oedema out of all proportion to 
the lesion with which it is associated is always suggestive of anthrax. 

To complete the diagnosis a drop of pus from a pustule or in its 
absence, fluid from the red area is drawn into the needle of a 
hypodermic syringe to be examined microscopically, the operator 
observing due precaution in the operation. The bacilli stain readily 
with fuchsine. 

The adjacent lymphatic glands enlarge and often suppurate; 
metastatic abscesses form ; and the constitutional symptoms superven- 
ing are those described in connection with Equinia. If recovery is to 
ensue, the gangrenous mass will slough as in favorable cases of car- 
buncle ; if the result is to be fatal, the process rapidly is aggravated 
by oedematous infiltration extending to a wider area and by greater 
tissue-necrosis. 

In some cases the accompanying fever is high, with marked 
delirium ; in other cases it is of a typhoid character. Death results 
from shock, septicaemia, or exhaustion, though in cases in which the 
lesion is circumscribed and unattended by constitutional symptoms 
recovery may ensue. 

Etiology. — This disease is induced by infection from one of the 
lower animals, usually horned cattle, that suffer from charbon or 
splenic fever, and are handled by herders, ranchmen, etc. The sus- 
ceptibility of the carnivora to the disease is very much less than that 
of the herbivora. It is claimed that not only direct inoculation may 
produce the disease, but that it may be transmitted through the 
medium of flies and other insects. More recently it is asserted that 
food, drink, and even inspired air may be the medium by which the 
disease is conveyed. The victims are chieflv male adults, 




354 HYPEE^MIAS AND INFLAMMATIONS. 

Pathology. — Since the first investigations reported in 1864 by 
Davaine to the French Academy, Pasteur, Klebs, Koch, Carnevin, 
and others have demonstrated that splenic fever is solely due to the 
multiplication in the blood and tissues of a rod-shaped bacillus, the 
hurl! I us anthracis, which is non-motile and transparent, measuring 
from 1 to 1.5 /t to 5 to 20 /*-. Under culture the bacilli may develop 
long filaments many times larger than the original rods, with a 
distinct sheath about a protoplasmic cylinder, 
which filaments after segmentation furnish oval 
shining spores. These spores have been culti- 
vated in generations, with resulting germs that 
produced the disease artificially in the lower 
animals. 

The pathological anatomy of malignant pus- 
/#<£ ^%@ ' tule is that of carbuncle, with the added fact 

\<*l$* Jj%? that specific bacilli and spores are everywhere 

present in the blood and debris of tissue. There 
rini : '!nTpulcoipul e ci b es: is an almost characteristic (edema of the papil- 
i About x 300.) lary body, according to Unna ; the margin of the 

epithelium is well preserved ; there is an acute 
vesicular elevation of the horny stratum without a previous break- 
ing up of the connective-tissue layer, and this induces a stretching 
of all the cavities in a vertical direction. 

Diagnosis. — The characteristic features of typical malignant pus- 
tule are its central eschar, its crown of vesicles, and its indurated 
base. In establishing a diagnosis care must be taken to avoid one 
source of error. Malignant pustule in man is not of frequent occur- 
rence in America, but occasionally various cutaneous eruptions are 
produced upon the hands after contact with animals or their hides 
upon which chemical solutions have been applied for the destruction 
of lice. These solutions usually contain arsenic, corrosive sublimate, 
or other substance capable of exciting a localized dermatitis. Chan- 
cre of the face, carbuncle, and poisoned wounds are all differentiated 
by their relatively indolent course and the absence of gangrene. 

Treatment. — The treatment is to be conducted on the principles 
« >f general therapeutics. Deep incisions of the lesion, extended to 
tin subcutaneous connective tissue, are. of ten successful when prac- 
tised before the occurrence of general symptoms. 

Successful results have also been obtained from incision and iodo- 
form dressings. Ilelna was not in favor of early cauterization of 
(lie malignant pustule, and it may be considered a questionable 
method of procedure. A grave case of malignant anthrax is recorded 
in which recovery ensued after hypodermatic injection of tincture of 
iodine. Three syringefuls of pure tincture were deposited beneath 
the skin at the periphery of the diseased surface, and lint saturated 
with i lie same fluid was applied over the slough. Internally, 15 
drops of iodine tincture (1.), with 3 grains (0.20) of potassium 
iodide, were also administered. -Normal cicatrization followed in 
this and six other cases recorded, 



EQUINIA. 355 

Crucial incisions with the free application afterward of pure 
carbolic acid have been followed by good results. Internally, sodium 
hyposulphite and quinine are successfully employed. The febrile, 
typhoid, and adynamic features of the disease are to be treated in 
accordance with the recognized principles of general medicine. 

Prognosis. — The disease proves fatal in about one-third of all 
cases. Early excision gives promise of satisfactory results. 

EQUINIA. 

(Lat., equus, a horse.) 
(Glanders, Farcy, Maleeus. Fr., Morve, Farcin. Ger., 

RoTZKRANKHEIT, MaLIASMUS. ) 

Equinia is a contagious, virulent, and inoculable disease, trans- 
mitted to man from the horse, mule, ass, or other animal ; and pro- 
duced by a bacillus resembling that of tuberculosis. It is conveyed 
either directly or mediately by the application of cloths and other 
articles which have been in contact with the bodies of infected 
animals. 

Symptoms. — The acute form of this disease commonly follows a 
period of malaise lasting a few hours or a few weeks, during which 
period the patient complains of vague pains of a rheumatoid type, 
followed by thermal variations. The body-temperature rises rapidly 
to the point of danger, with chills, fever, diarrhoea (often following 
constipation), and rapid exhaustion, the picture being suggestive 
of acute septicaemia. 

The cutaneous symptoms begin often with an erysipelatoid blush, 
the infected and swollen surface also producing papules, vesicles, 
pustules, and bullae, with dense but ill-defined induration of the sub- 
cutaneous tissue; or reddish and yellowish papules appear, which, as 
in the case of the fluid-containing lesions, coalesce and furnish a 
bloody discharge. These symptoms, in the case of inoculated disease, 
may develop on the site of the healed or healing wound of entry of 
the virus, and later become generalized. Sloughing ensues more 
or less rapidly, sometimes with extensive gangrene, though the pa- 
tient often succumbs before the culmination of the morbid process. 
The lymphatic vessels are swollen and well defined, often indurated 
nodules (farcy-buds) forming in the lymph-glands and -channels. 
These symptoms chiefly affect the face, hands, feet, and other ex- 
posed parts of the body. There is often a sanious or purulent and 
offensive discharge from the nostrils, the mouth, and the eyes, the 
inflammatory process spreading rapidly to the deeper mucous sur- 
faces. This catarrh, chiefly nasal in site and declared conspicuously 
by the nasal voice due to the blocking up of the nostrils by the viscid, 
foul-smelling, hemorrhagic discharge, is one of the most characteristic 
features of the malady, and is of importance in the diagnosis. 

In the chronic form of the disease the nasal catarrh is less conspic- 



356 HYPEREMIAS AND INFLAMMATIONS. 

nous at the outset, though later it may be a prominent feature of the 
malady. A few days or weeks after infection, pustules, as in the 
acute form, resembling those of variola, but flattened and never um- 
bilicated, begin as vesicles or even as papules, coalesce to bullne, occur 
in successive crops, and proceed to the production of multiple ab- 
scesses, poorly defined on the extremities and about the face, much 
more rarely developed on the trunk. These abscesses may be of phleg- 
monous type; or be deep, brawny infiltrations with purulent foci, 
extending over months of invasion and decline of the disease. From 
these abscesses, pea- to nut-sized over the face, larger on the limbs, 
flows an abundant, sanious, semiliquid or viscid, yellowish, offensive 
pus. Ulcers form at many points, with purplish borders, oval or 
roundish eon four, and thin edges, suggesting the scrofulous ulcer of 
classical type. The edges may be soft or indurated. By this multi- 
plication or coalescence the lips, nose, eyelids, and other parts of the 
face may be destroyed in part or wholly. The disease may steadily 
advance or may seem to be arrested for a time and reawaken to 
activity. Meantime the lymphatic glands are either unchanged or 
are enlarged by sympathy. In the course of months or years there is 
a fatal issue. The disease is, fortunately, rare. 

Meyer and Crohn 1 fully reported a case of acute glanders from 
New York City in 1907, and Bevan and Hamburger 2 reported three 
cases occurring in Milwaukee in the same year. A fatal case oc- 
curred in the Presbyterian Hospital of Chicago in 1908 in a physician 
infected from laboratory cultures with which research work was 
being performed. 

Etiology and Pathology. — Equinia is almost invariably produced 
by infection from horses, a history of contact with such animals being 
one of the important points in establishing a diagnosis, though rarely 
it is transmitted also from man to man. The infection is produced 
by the glanders-bacillus (Weichselbaum, Schiitz Loftier, Bouchard). 
This organism is nearly of the size of the tubercle-bacillus, having 
been cultivated and found capable of producing the disease in the 
lower animals after injection of cultures. The bacilli are abundant 
in papules, abscesses, blood, and brain-tissue. 3 

Diagnosis. — Tn all cases the clinical diagnosis should be substan- 
tiated by the Strauss' method. An agar-agar culture of the glander 
bacillus or secretion from lesions is injected into the peritoneum 
of a male guinea pig. Within seven days an orchitis develops from 
which the bacillus may be recovered. 

1 Acute Glanders. Report of a case with review of recent literature and a 
complete bacteriologic report. J. A. M. A., 1907, 1., pp. 1593-1595. (A com- 
plete report including reference to nine additional cases reported to the New 
York Board of Health during the two preceding years.) 

2 The Occurrence of Glanders in Man, Ibid., 1907, 1., pp. 1595-1599. (A full 
report clinical and bacteriologic of three cases. — Bibliography.) 

3 Cf. Coleman and Ewing, Jour. Med. Resch., 1903, ix., p. 223 (report of case 
with autopsy, histological and bacteriological findings, and bibliography). 

* Archives de M6d. expSrim., 1888. 



PLATE IX 




Cutaneous Lesions in Equinia. (Howard Morrow.) 



DISSECTION-WOUNDS AND ANIMAL POISONS. 357 

Treatment is that of the septic condition, and is of little avail. 
Prognosis, is in the highest degree grave. 

DISSECTION-WOUNDS AND ANIMAL POISONS. 

Aside from verruca necrogenica, or anatomical tubercle, described 
in the chapter on Tuberculosis Cutis, lesions generally known as " dis- 
section-wounds " occur with symptoms of acute poisoning upon the 
hands of those exposed in post-mortem examinations and dissections. 
At the inoculation-point, which may be either the site of a former 
abrasion, a rent, or the mouth of an open follicle, a painful vesico- 
pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla 
rapidly rises from an angry and indurated base with hypersemic 
areola of dull-red shade. Suppuration, crusting, or ulceration, lim- 
ited to the seat of the lesion, may follow; or there may occur lym- 
phangitis in various grades with consequent pysemic or septicemic 
involvement of the system. Suppurative and non-suppurative axil- 
lary buboes are common. Gangrene and necrosis of the soft parts 
and the bones, especially the phalanges, may ensue, as may also a 
fatal result from the systemic disorders named. Rarely an acute 
and fatal septicaemia may result when the lesion at the point of inocu- 
lation is so slight as to pass unnoticed. In a few cases chronic maras- 
mus is induced. 

Post-mortem pustules originate from infection with cadaveric 
poisons in the dissecting-room or dead-house. A pruritic macule 
either at the site of an abrasion or elsewhere soon develops, and is 
transformed into a vesico-pustule with a reddish halo, which bursts, 
and is covered with a crust beneath which pus repeatedly forms. 
Occasionally there is coincident adenopathy. 

The nature of the infection varies in different cases. It is most 
commonly due to pyogenic bacteria, but may be caused by the specific 
microorganisms of tetanus, erysipelas, anthrax, or other infectious 
disease. The absorption of toxines resulting from the decomposition 
of animal tissues is undoubtedly an important factor in the infection. 
Treatment. — The wound should be cleansed and opened and a 
moist dressing of alcohol three parts and water one part applied both 
to the wound and the accompanying lymphangitis. 

Pustules and othee Lesions resulting feom Wounds 
inflicted by Reptiles and Insects are often of an insignificant 
character. Such are the trivial results of the bites or the stings of 
flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, how- 
ever, serious and even fatal consequences have been recorded. The 
wounds produced by the tarantula and the scorpion (which frequently 
lurk in the clusters of tropical fruit now imported to almost every 
part of the United States), as also of venous reptiles, may prove to 
be grave. Urticarial, vesicular, pustular, papular, bullous, and 
petechial lesions may thus originate and be the cause of a more or 
less severe dermatitis. See also Chapter on Myiasis. 



358 HTPEB^EMIAS AND INFLAMMATIONS. 



ERYSIPELOID. 

(Erysipelas Ciikoxicum, Progressive Phlegmon, Crab Cel- 
lulitis, Erythema Serpens, Erythema Migrans.) 

This term is employed by Eosenbach 1 to designate a special in- 
flammation of the integument occurring as a complication chiefly of 
traumatisms. Winn a wound is infected with the special poison of 
the disease a peripherally spreading, tumid, and empurpled halo en- 
circles the site of infection, which slowly disappears in the part origi- 
nally attacked while it extends progressively to another area. The 
advancing border of the disease is distinctly circumscribed, and may 
be festooned or scalloped. Kew points may appear from which the 
violaceous redness spreads, while others are in a state of apparent 
inactivity. This affection may be complicated with furunculosis, but 
scaling is said never to occur. Itching and burning sensations are 
usually present. 

Rosenbaeh believes that the source of this disease is a micro- 
organism of the order Cladothrix, existing in putrid flesh and cheese, 
from pure cultures of which organism he is reported to have induced 
the disease. (Jilchrist 2 found no microorganisms in his cases and he 
did not succeed in producing the disease in healthy susceptible indi- 
viduals by inoculation of blood taken from the lesions of those suffer- 
ing from the disease. He believes that it is not microbic but a toxic 
erythema. 

The disease affects chiefly the fingers and hand (according to 
Elliott, also the scratched toes) of scullions, meat-dressers, fish- 
dealers, poultry-cleaners, and persons of similar occupations. The 
distinction between this disorder and erysipelas is based chiefly on 
the indolence of the former, its more superficial involvement of the 
skin, and the absence of constitutional symptoms. It is to be care 
fully distinguished from Crocker's "dermatitis repens " (some in- 
stances of which may be here included), from erythema multiforme, 
from erythema iris, and from ringworm of the hands. 

Treatment. — Treatment is efficient with local application of for- 
malin, ichthyol, resorcin, pyoktanin-blue, pyrogallol, potassium per- 
manganate, or the mercurials in salves or in lotions. 

ERYSIPELAS. 

(Gr., ipvdpuq , rod; ~t'/'/ a , the skin.) 

(St. Anthony's Fire. Ger., Rothlauf, Erysipel. Fr., Ery- 
sii-ki.k. La Rose. | 

This is a migrating streptococcus infection of the deeper structures 
of the skin spreading through the lymph spaces without following the 
lymph current. 

1 Verhandl. der deutech. Genii, fiir Chir., 1887, xvi., p. 75. 
-M. C D., 1904, p. 507 (complete literature). 



M&7S1PELA8. 359 

It is one of the most dreaded of infectious diseases. The occur- 
rence of a case in hospital practice necessitates the discontinuance 
of all surgical operations, the removal of the patient to an isolation- 
pavilion, and thorough disinfection of the bedding and the room 
occupied by the patient. 

In private practice physicians doing surgical and obstetrical work 
should not treat erysipelas,- nor should the attending physician touch 
the morbid area without subsequent thorough disinfection of the 
hands. 

Symptoms. — This disease is usually preceded by a prodromic 
period of malaise (lasting for twenty-four hours or less), which may 
be ushered in by one or several chills followed by febrile symptoms. 
The latter are accompanied by anorexia and often by vomiting with 
general depression and headache. 

The eruptive symptoms are generally first displayed at a given 
point, from which the disease progresses. It is commonly first noticed 
in a nut- or egg-sized patch, the integument of which is tumid, 
slightly elevated, irregular in contour, distinctly circumscribed, with- 
out peripheral islands (these are of importance in the diagnosis of 
erysipeloid), and which presents a rosy or crimson-reddish color with 
a peculiarly smooth and characteristic shining or glazed appearance. 
The sensations awakened may be those of moderate pruritus, of pain, 
heat, or burning. To the touch the affected part is tender, moderately 
firm, and perceptibly hotter than normal. The color fades under 
pressure to a yellowish white. 

In typical cases the erysipelatous blush and swelling spread over 
an area which may be of the size of the palm, or may even cover 
the surface of an entire limb or large area of the body. In cases of 
moderate grade the inflammation attains a maximum of extent and 
severity within a week, remains apparently unaltered for a day or 
more, and then begins to abate, with amelioration of all the con- 
comitant symptoms. The fever, which often precedes the eruption, 
continues unabated during its progress, the temperature rising to 
105° or 106° F., with nocturnal exacerbation, cephalic and lumbar 
pain, dryness of the tongue, gastric distress, and occasional delirium. 
As involution of the disorder is accomplished the redness is replaced 
by the brownish, bluish-red, and dirty-white shades often seen after 
the disappearance of erythema multiforme, the epidermis finally 
desquamating in various degrees according to the extent of the pre- 
ceding inflammation. 

In other cases, in which the exudation of serum beneath the epi- 
dermis has been rapid, the epidermis is raised in the form of vesicles, 
pustules, or bullae, more often the latter, and precisely as in the severe 
forms of dermatitis calorica, with which erysipelas presents a certain 
analogy, gangrene of the skin may result in the part affected. This 
complication is particularly liable to follow the disorder when it 
attacks the seat of surgical wounds and injuries. 

Surgical accidents aside, the face is the commonest seat of the dis- 



360 HYPEREMIAS AND INFLAMMATIONS. 

ease, on which the blush may be first seen upon one side of the nose, 
a cheek, a lip, or an eyelid. It often attacks the lobe of the ear after 
the operation of piercing the lobule for the insertion of ear-rings in 
women; thence it may extend over the whole face, inclusive of the 
mucous linings of the mouth and the nose, that present a dry, tumid, 
and glazed appearance, suggestive of the symptoms displayed upon the 
skin. The inflammation may extend to the hairy parts, but in many 
cases it exhibits a species of reluctance to transgress the limits there 
presented. It may be noticed in cases of mild grade, in which no 
applications have been made to arrest a local progress, that the ele- 
vated border spreads symmetrically to within a few lines of the male 
beard or the hairs at the edge of the forehead, and there is arrested. 
In severer grades these limits are surpassed, and then, as a rule, the 
extension is rapid and formidable. In this way the entire head may 
become enormously swollen, suggesting to a casual observer that it 
is twice its normal size. The patient then is greatly disfigured; 
his scarlet lips are swollen and parted, permitting the escape of saliva ; 
the ears, as usual when greatly enlarged, project in a marked degree 
from the side of the head ; the eyelids 'are oedematous and incapable 
of separation ; the face is disfigured by bulla? or crusts ; and the mind 
disordered in the violence of the fever or the accesses of delirium. 
When recovery ensues the hairs generally fall. 

All regions of the body may be invaded, such as the vaccinated 
arm, the leg the skin of which is involved in venous varicosities, the 
scrotum or the umbilicus of the infant, the genitalia of the newly 
delivered woman, the breast of the nursing-mother, and every surface 
which has been the seat of punctured, incised, contused, or poisoned 
wounds, or other accidents of the integument to which the germs of 
the disease may have had access. 

The febrile symptoms are, throughout, persistent and character- 
istic of a specific toxaemia. The body-temperature, as has been seen, 
may reach 105° to 107° F., with vespertine exacerbations and remis- 
sions ; it may also become subnormal. If not relieved in the course of 
seven or eight days, complications may be expected, namely, oedema, 
abscess, phlegmonous inflammation, gangrene, or inflammatory acci- 
dents involving the membranes of the brain, lungs, heart, bowels, 
kidneys, peritoneum, or joints, together with coma and delirium. 
I )eath may result from the complications or from shock, exhaustion, 
or pysemia. 

Erysipelas Ambulans. — This is a term used to describe that form of 
the affection in which the erysipelatous blush, after involving a given 
area, spreads with greater or less rapidity to the parts in the vicinage, 
either by direct extension and uniform advancement in one direction 
of the tumid and distinctly circumscribed border, or by linear, digi- 
tate, or irregular prolongations radiating from the inflammatory focus. 
As the blush and swelling advance in one direction there is usually a 
correspondingly rapid disappearance on the other. At other times the 
disease, while extending to a new area and abandoning the old, is 



EHTS1PELAS. 361 

relighted in the latter, and thus an irregularly involved and irregu- 
larly extending erysipelatous surface presents for weeks the varying 
phenomena of the disease. In yet other cases, chiefly those in which 
there has been a history of traumatism, a long erysipelatous linear 
streak or band may spread from the site of the traumatism in one 
direction or another, suggesting the indurated lines observed in 
lymphangitis. 

Chronic Erysipelas. — Habitually recurrent and indolent erysipela- 
tous attacks, the identity of which with the disease here described it 
is difficult to establish, occur frequently. Some of these cases are 
due probably to repeated infection with bacteria which may be attenu- 
ated or less virulent forms of the cocci found in the severe types of 
erysipelas. Many cases, however, reported as " chronic or recurring 
erysipelas " are instances of eczema, dermatitis, or rosacea which are 
subject to acute exacerbations. Instances occur in which the face, 
wholly or in part, is the seat of a low grade of inflammation with local 
heat, swelling, redness, considerable infiltration, and some tenderness, 
the skin being irritable and worse after exposure to a high wind or 
after excesses at the table. But most of such cases fail to exhibit the 
distinct imprint of erysipelas ; they are not only chronic in course, but 
are also exceedingly indolent, often lasting for years ; they are unac- 
companied by fever ; they distinctly are limited in all accesses of ag- 
gravation to the same part of the face ; they are characterized rarely 
by a bullous efflorescence; many occur in the subjects of chronic 
alcoholism ; and the specific germs of erysipelas are not present. 

Etiology. — Erysipelas is caused by the streptococci of Fehleisen, 
or other organisms, which gain admission to the tissues through some 
lesion of the surface. The site of infection may be a surgical or other 
wound, or it may be a slight scratch or an unrecognized abrasion of 
the skin or mucous membrane. 

In the face, catarrhal and ulcerative processes involving the mu- 
cous membrane of the mouth, ears, and nose are often the cause of 
erysipelas, these processes occurring in a wide range of disorders from 
syphilis of the nasal bones to caries of the teeth. Tuberculous and 
other ulcers, as well as eczema and several skin-diseases, frequently 
furnish a means of ingress to the streptococci. Injuries of, and sur- 
gical operations upon, the scalp not conducted with antiseptic pre- 
cautions, and the common piercing of the lobe of the ear in women 
and female children for the insertion of ear-rings, may be followed by 
the appearance of the disease upon the scalp, as a result of which the 
hair often falls. Fistules, vaccination, lesions of the tender umbilicus 
of the newborn infant, and railway accidents may be named as com- 
mon causes of the disease in other regions. 

Predisposing causes of this disease are to be sought for in ca- 
chexia, general debility, alcoholism, kidney-disease, epidemic influ- 
ences, traumatism, violation of hygienic rules, idiosyncrasy, and oc- 
casionally the recurrence of previous attacks. 

Jordan 1 and others have demonstrated apparently that the disease, 
1 Miineh. med. Wchnschrft., 1901, p. 1371. 



362 ttYPBR&MlAS AXD INFLAMMATIONS. 

in both mild and severe forms, may be produced by staphylococci as 
well as by streptococci. Jordon has shown that typical erysipelas 
may be produced in the rabbit by a number of different cocci. 

Pathological Anatomy. — The disease is an acute inflammation of 
the skin and of the subcutaneous tissue. Tuna, whose examinations 
were made largely in the skin of children and infants, found in- 
variably a simultaneous invasion of both the cutis and the hypoderm 
in erysipelas, the former recovering far more rapidly than the latter, 
and rarely reaching such a grade of activity. The venous capillaries 
were all enormously distended, as if paralyzed by the poison present, 
and the collateral lymphatics with the lymph-spaces were equally 
dilated. All the cutaneous vessels swarmed with streptococci, both in 
the central and the marginal zones. 

Diagnosis. — Erysipelas is to be distinguished from the erythe- 
mata, from dermatitis of various grades, from eczema, and from 
scarlatina. As a rule, its recognition is readily effected when the 
presence of the fever in erysipelas is kept in view, as also the peculiar 
shining, swollen, and rosy-reddish to damask hue of the affected parts. 
The redness is never produced, as in scarlatina, by multiplicity of 
reddish puncta, nor is it so widely diffused as in that disease. Ery- 
sipelas may at times be accompanied by a pruritic sensation, but the 
patch which it affects is never by any possibility scratched. By this 
simple test alone one may often distinguish an erysipelas of the face 
from an eczema of the same region in a child. From a chronic derma- 
titis with thickening of the affected tissues and redness of the surface, 
erysipelas is to be distinguished by its tendency to spread, by its 
acute course, by its frequent association with bullous or vesicular 
lesions, and by the color, outline, and raised border of the affected 
patch. However, it must be understood that to these localized 
patches of chronic dermatitis several authors have given the name 
" chronic erysipelas," the difference between the views held on this 
point being chiefly one of titles. 

Treatment. — The method of treating erysipelas by the administra- 
tion of the tincture of iron internally has long been popular among 
American practitioners, but its efficiency is questionable. This prepa- 
ration is given in full dose-, from 10 to 50 drops, day and night 
i-vcyy two to three hours, irrespective of the febrile state. 

The constitutional treatment is important, but is solely symp- 
tomatic, and should be directed to lowering the temperature, to ob- 
taining proper functional activity of all the organs of the body, and 
in prolonged cases to sustaining the strength of the patient. Locally, 
no matter what application is made to the surface, the affected area 
should be covered with gauze and bandaged. Equal parts of ichthyol. 
lanolin, and vaseline make a very satisfactory dressing for the average 
case. It may be applied once or twice daily. Frasor 1 uses pure car- 
bolic acid. As Boon as the skin becomes white it is mopped with abso- 
lute alcohol. The purpose of Buch treatment is to limit extension of 

1 Brit. Med. Jour., 1901. 



EKYS1PELAS. 363 

the disease. It is true that these measures will not always succeed, 
but it is erroneous to assert with some authors that they always fail. 
Certain it is that, whether effective or not in the production of the 
result, the advancing border of the disease will often fail to surpass 
the limits thus artificially described. Heppel 1 recommends the paint- 
ing over the surface of a 10 per cent, solution of carbolic acid in 
alcohol, as an abortive treatment, for which Braithwaite 2 substitutes 
a solution of tannin of the same strength. 

Good results have been reached in the local treatment of erysipelas, 
first by attempting to limit the extension of the disease by the appli- 
cation of the tincture of iodine over the peripheral zone, and, sec- 
ondly, by retaining over the entire surface affected neatly applied 
compresses saturated with a solution of sodium hyposulphite in the 
strength of about 1 drachm (4.) to the ounce (30.), or with 95 per 
cent, alcohol. 

Attempts to limit extension of the disease by local applications 
of an irritating sort (corrosive sublimate, silver nitrate, carbolic acid, 
tar, turpentine, etc.) are sometimes positively injurious. Dry heat 
applied by the aid of cotton or wool, cold compresses, or iced lead- 
lotions with intermissions of application, salicylic acid, boric acid, 
iodol, resorcin in solution, or iodoform in powder may be used. A 95 
per cent, alcoholic or a saturated solution of boric acid often gives 
good results if painted frequently over and for an inch or more be- 
yond the affected area, or if applied on compresses. 

Koch applies 1 part of creolin, 4 of iodoform, and 10 of lanolin, 
covered with gutta-percha. Hallopeau praises 1 part to 20 of sodium 
salicylate in aqueous lotions upon folds of linen. Tabit claims to 
abort the disease with 10 per cent, solution of iodol in collodion. 
Injections of anti-streptococcic serum have been used with varying 
success. 

It is needless to add that all surgical indications are to be fully 
met when they are present: pus is to be evacuated, crusts removed, 
and drainage secured. 

Finally, there are forms of erysipelas which are remediless ; they 
are usually septic in character. The scarlet blush spreading from an 
irreparable injury of long duration is often the last protest of Nature 
against the damage which even her final resort of gangrene will not 
avail to repair. 

Prognosis. — Under favorable circumstances erysipelas, even of 
severe grade and extensive invasion, terminates in complete resolu- 
tion. Reserve should be made, however, in every case, as a serious 
complication has often transformed the simplest into the gravest form 
of the disease. The very young, the cachectic, the victims of drink, 
the aged, the inmates of hospital-wards depressed by other illness, and 
those mentally distressed by destitution and neglect, are particularly 
liable to suffer from grave and fatal forms of the malady. 

1 Arch, of Derm., April, 1881. 

2 Brit. Med. Jour., April, 1881. 



364 HYPEREMIAS AND INFLAMMATIONS. 

The patients who fill the beds in most lying-in hospitals are young 
women, either unmarried or deserted by their husbands, and unpro- 
vided with the necessities of life by those upon whom such a respon- 
sibility rests. The mental depression thus originating in connection 
with septicemic influences is responsible for much of the relation 
which erysipelas often seems to sustain to the puerperal state, as also 
for the appalling mortality which it may exhibit under these circum- 
stances. 

DERMATITIS REPENS. 

Under this title Crocker first described an inflammatory disease of 
the skin (usually a consequence of injuries) spreading with a mar- 
ginate border, and, as a rule, beginning over the upper extremities. 
Oases have since been reported by Garden and Nepveu, Hartzell, 1 and 
others. 

The inflammation spreads from a traumatism, eventually produc- 
ing a raw, reddish surface denuded of epidermis and oozing at several 
points, the serous exudate also undermining the apparently sound 
cuticle. The disease spreads with uninterrupted regularity, lasting 
for months, and in cases invading the larger part of an upper ex- 
tremity. Extension occurs by the appearance at the periphery, of 
new vesicles or small blebs, or by the elevation of the adjacent epi- 
dermis with the fluid exudate. In either event, detachment of the 
epidermis leaves the characteristic, denuded, red surface. There is a 
definite margin to the affected patch. The disease may begin with 
the formation of blisters. 

The disease has originated in cicatrices after amputation of a 
finger, from burns, from irritation of the feet after walking barefoot 
on sand, and from splinters under the nail. Crocker believes that the 
dermatitis results from peripheral nerve-irritation, and that there is a 
secondary parasitic involvement of the part. The disease seems to be 
an infectious dermatitis, the traumatism being simply an initial fac- 
tor of the process. The parchment-like epithelium often left after 
healing shows that the process may be one of considerable destruc- 
tion of epidermal and dermal tissues, which may result in diffuse but 
superficial atrophy and cicatrization. The diagnosis from eczema 
depends chiefly upon the recognition of the limited outline of the dis- 
ease, the entire denudation of the surface, the undermined edge, and 
the thinned, shining epidermis left after healing. The affection is to 
be treated as a parasitic dermatitis. 

Two cases of this disease were supposed to have originated in the 
minute traumatisms of the finger-nails occurring when farm-laborers 
are engaged in husking Indian corn by hand ; and one well-marked 
case followed the amputation of a finger. An excellent illustration of 
the disease is given in a colored lithograph accompanying the report 
of a ease by Stowers. 2 

1 J. A. M. A., 1902, ii., p. 1581 (brief summary of reported cases). 

2 B. J. D., 1896, viii., p. 1. 



DERMATITIS REPENS. 365 

In three cases treated by us success was obtained in one after em- 
ploying locally a saturated solution of pyoktanin-blue. In another 
case that had resisted continued and varied treatment the lesions dis- 
appeared rapidly under application of a solution of sodium hypo- 
sulphite. Still another case yielded to applications of strong white- 
precipitate ointment. Crocker recommends a strong solution of 
potassium permanganate. 

Acrodermatitis Perstans (Acrodermites Continuees Hallopeau). — 
Under this title Hallopeau, Audry, 1 Crocker, and others describe a 
condition very similar to that of dermatitis repens in that it begins on, 
and often is limited to, the extremities; originates frequently in 
traumatism ; begins often as a vesicle spreading peripherally ; and is 
rebellious to treatment. Hallopeau describes vesicular, bullous, and 
purulent types. The disease begins frequently on a finger, to which 
it may be limited for weeks before it commences to spread. On rup- 
ture of the vesicles or pustules a reddened excoriation is left similar 
to that seen in dermatitis repens. The condition differs from derma- 
titis repens in the frequent appearance of secondary eruptions, often 
pustular in form, on portions of the body even at a distance from the 
region first affected, and larger areas frequently are formed by the 
coalescence of a number of foci. The secondary eruption may be in 
the form of an exfoliative erythema, and may involve symmetrically 
considerable portions of the body. The disorder further differs from 
dermatitis repens in the tendency to recur frequently in the same 
place. It is also more persistent and occasionally terminates fatally. 
The disorder is allied closely both etiologically and pathologically to 
dermatitis repens. 

The treatment is practically the same in both disorders. For 
acrodermatitis, Hallopeau recommends a solution of silver nitrate, 1 
drachm (4.) to the ounce (30.). 

DERMATITIS GANGRENOSA (SPHACELODERMA). 

Gangrene of the skin may result from a dermatitis originally due 
to the action of either excessive cold or heat; to the action of exter- 
nally applied chemical agents (caustics, strong acids, alkalies, etc.) ; 
to shock ; to ergot and other substances ingested ; to infectious diseases 
(lepra, tuberculosis, syphilis, erysipelas) ; to central nervous diseases 
(decubitus, Raynaud's disease) ; to disorders of the blood-vessels 
(embolism, thrombosis, acute and chronic endarteritis obliterans, cal- 
careous changes in the arterial vascular tunics) ; to compression of ves- 
sels by ligature, by tumors, or by inflammatory products. 

Multiple Gangrene of the Skin due to local infection of tissues hav- 
ing diminished power of resistance may complicate typhoid fever 
(Huhl) 2 ; malaria (Osier 3 ); erythema multiforme 4 ; and other dis- 

'Annales, 1901, s. iv., ii., p. 913 (with summary of reported cases). 
2 Amer. Jour. Med. Sci., 1900, p. 251 
s Johns Hopkins Hosp. Bull., 1900, p. 41. 
* Archiv, 1905, lxxviii., p. 247. 



366 HYPEREMIAS AND INFLAMMATIONS. 

eases ; it may occur without the cause of diminished resistance of the 
tissues being determined. Hartzell, 1 Wende 2 and others 3 report cases 
in which the lesions were apparently auto-inoculable, and in which 
bacilli and cocci were demonstrated. 

Nosocomial Gangrene. — It is now recognized that this form of 
gangrene, which under favorable conditions is contagious, is due to 
the Vincent bacillus. Through the work of Matzenauer, and Rona, 4 
it has been shown that this bacillus sometimes causes gangrene in 
ulcers of the skin. 

The most common form of gangrene of the skin has been described 
by Hallopcau. 5 The infection occurs on the face, especially on the 
forehead, as an acne-like papule, the epidermal covering of which 
quickly exfoliates, leaving an ulcer, which may remain superficial 
and disappear leaving a scar, or it may be covered with an eschar 
which may persist unchanged for a long time, or the process of ul- 
ceration may extend under the eschar, or groups of new papules may 
develop ; the same disease may affect the mucous membrane of the 
mouth and the lymphatic glands may become involved. The disease 
should not be treated with moist dressing; dusting powders or oint- 
ment produce better results. 

Diabetic Gangrene occurs most frequently upon the toes and 
feet, though on other portions of the extremities and even elsewhere, 
of patients affected with glycosuria. The first lesions are usually 
blebs which, after evolution, desiccate in the center and furnish black 
crusts, new lesions often springing into existence at the periphery, 
thus producing a serpiginously spreading area with vesicular border. 
Either dry or moist gangrene of the affected part may result. At 
times extensive sloughs form, one or several digits, or the whole 
foot, falling spontaneously, or requiring removal by the expedients 
of surgery. The danger, however, of surgical interference in these 
cases is obvious. Cases are on record where gangrene of the fingers 
and toes has occurred in diabetic patients without the previous occur- 
rence of blebs. We have had under observation several cases in 
which there had been precedent syphilis where pancreatic gummata 
were believed to exist ; and also have observed symptoms of equal 
gravity where there was no luetic history. The association of gan- 
grene with diabetes is believed to be due in part to the fact that the 
tissues of patients suffering from the disease last named, in conse- 
quence of weakened resistance furnish a favorable medium for the 
growth of bacteria. 

The treatment of these eases, though exceedingly unpromising, 
is at times rewarded with excellent results. Many cases prove fatal. 
Surgeons are rarely justified in amputation; but removal of dead tis- 

i Amer. Jour. Med. Sci., July, 1898. 

J. C. D., 1906, p. 445. 
'Sailer, Amer. Jour. Med. Sci., 1902, exxiii., p. 59; and Bernard and Jacob, 
Arch. Med. exp. et d'Anat. path., 1903. 
♦Archiv, 1904, lxxi., p. 191. 
Annales, 1895, s. \i\., vi., p. 213, 



DERMATITIS GANGRENOSA INFANTUM. 367 

sue is of advantage in many cases. We have had the best results by 
careful attention to the general condition of the patient; by local 
asepsis; and by mummification of gangrenous tissue by continuous 
immersion in a solution containing five parts of the acetate of 
lead, twenty-five of crude alum, and five hundred of water. 

DERMATITIS GANGRENOSA INFANTUM.* 

(Multiple Disseminated Gangrene of the Skin in Infants, Vari- 
cella Gangrenosa, Pemphigus Gangrcenosus, Rupia Escharotica, Gan- 
grenous Infantile Ecthyma. Fr., Ecthyma terebrant.) — As a conse- 
quence of the exanthemata (variola, varicella, rubeola, vaccinal erup- 
tions) the head, shoulders, and trunk of some children exhibit crust- 





Fig. 66. 










^&rm 






~'"WW ^H 






4|| 




. 


""-'■" 


'^^^^W^ . 








I 



Dermatitis gangrenosa infantum. 

covered lesions which ulcerate and finally throw off a gangrenous, 
split-pea- to small-coin-sized, deep or shallow slough, after which re- 
pair commonly occurs. Severe losses are produced by a species of 
coalescence of smaller ulcers. 

These gangrenous points may occur beneath some previously 
existing lesion or crust, or they may at the outset be spontaneous. In 
most cases there forms a vesicular lesion with rosy areola, that speed- 
ily bursts, leaving a blackish slough about which a circle of eliminat- 
ing inflammation spreads. Thromboses result in the blood-vessels of 
the neighboring parts, oedema follows, and there is excited a train of 
reactive symptoms — fever, vomiting, diarrhoea, albuminuria, cardiac 
or pulmonary troubles. The patient becomes greatly emaciated. 
Crocker reports hemorrhagic vesicles and bullae in grave cases. 

1 Cf. Veillon and Halle, Annales, 1901, s, iv., ii., p. 402 (with review of 
literature), 



368 



HYPEREMIAS AND INFLAMMATIONS. 



Brocq is careful to distinguish between these grave forms of 
disease and those to which should be denied the appellation dermatitis 
gangrenosa. In these milder forms vesicular lesions may develop, 
simulating those of varicella, occurring perhaps in crops and accom- 
panied by a mild fever. Some among them may be covered with a 
blackish crust, may indurate at the base, surround themselves with 



Fig. 67 




Dermatitis gangrenosa infantui 



(Anthony.) 



an angry zone of inflammation, and especially about the trunk, the 
thighs, and the anogenital region, ulcerate beneath the crust. Even 
though these ulcers coalesce and acquire a grave aspect, the result, as 
a rule, is not unfavorable. 

Tim subjects of this affection are infants and young children, 
fn»m three months to several years of age. Beside the exanthemata 
which may precede, cases are on record following tuberculosis, 
rickets, and syphilis. The process is one which, originally depend- 
ent upon the toxic effects of specific cocci, evidently requires a special 
soil for its effective operation. 

Treatment. — The treatment should include support of the general 
system, with local antisepsis by the aid of boric-acid solutions, aristol ? 



EEBPES. 369 

iodol, and the dressing of the parts which slough by the usual deodor- 
izing agents. 

Prognosis. — The prognosis is at times grave. 

SYMMETRICAL GANGRENE OF THE EXTREMITIES (LOCAL 
ASPHYXIA, RAYNAUD'S DISEASE).! 

This is a paroxysmal symmetrical asphyxia of the extremities 
occurring mostly in weakly anaemic young women of nervous temper- 
ament. There is usually a prodromal period during which the patient 
experiences intermittent abnormal sensations, for example, pares- 
thesia in different regions of the body, headache, and general malaise. 
These symptoms are especially marked in cold weather. The symp- 
tom-complex indicates a profound disturbance in vascular inner- 
vation. 

A period of syncope may then follow ; the phalanges become sym- 
metrically pallid, bloodless, and the seat of intense pain. The disease 
may terminate with disappearance of these symptoms, or a stage of 
asphyxia may be reached. The affected fingers or toes may then 
change in color to a slate-gray or blackish color and fall into gangrene. 
The patient experiences great pain. These stages of the disease are 
not well marked in every case. 

Etiology and Pathology. — This disease occurs equally in the two 
sexes and at all ages, and often in the cold weather of the winter season. 
There is a growing suspicion that many cases are of syphilitic origin, 
as the disease has followed specific infection. It has also succeeded 
tuberculosis, diphtheria, the exanthemata, diabetes, and hajmoglobin- 
uria. It is apparently due to trophic disturbances, the exact nature 
of which has not been determined. By means of arrays Beck 2 dem- 
onstrated in two cases atrophic and other changes in the bones. 

Treatment is by employment of the galvanic current, stimulation 
(as in dermatitis with congelation), and friction with alcoholic, cam- 
phorated, or oleaginous lotions. It is desirable to apply both electri- 
city and (in some cases) dry cupping over the spinal region. Sys- 
temic treatment should be adapted to the underlying condition in 
each case. 

Prognosis is in some cases grave. When the morbid condition is 
limited to a small part of the body recovery is often satisfactory. 

HERPES. 

(Gr., epneiv, to creep.) 
("Fever Blisters." Fr., Dartre; Ger., Flechte, Blaschen- 

FLECHTE.) 

The term "herpes" is responsible for some of the confusion 
which has existed with respect to cutaneous diseases. By the ancients 

1 For bibliography, see monograph by Monro, Glasgow, 1899, and chapter by 
See, La Pratique Dermatologique, t. i., p. 436. 

2 Amer. Jour. Med. Sci., 1901. 



370 HYPEREMIAS AND INFLAMMATIONS. 

it was employed, as its etymology suggests, to designate a disease 
creeping or extending gradually over the surface or within the sub- 
stance of the skin. By several more modern authors the term is em- 
ployed in a generic sense in a futile attempt to distinguish a series 
of so-called " herpetic diseases," and even herpetic diatheses from 
those of a different complexion. The significance which attaches to 
the word in the minds of dermatological authors of to-day is ex- 
ceedingly simple, and is limited to the conditions described in the 
following paragraphs. Herpes zoster by some modern writers, is re- 
garded as identical in character with herpes simplex. As excellent 
authorities can be cited on both sides of the question, the diseases are 
here separated for clinical study pending a definite demonstration of 
their relations the one to the other. 

HERPES SIMPLEX. 

Herpes simplex is an eruptive disorder, often first declared in 
the site of the lesions by sensations of heat and burning. These are 
speedily followed by the occurrence of millet-seed- to coffee-bean- 
sized vesicles (single or relatively few in number, and in the latter 
case grouped), which may be preceded or accompanied by a general 
febrile process, though in many cases there is no constitutional dis- 
turbance. The vesicles are usually displayed symmetrically, are 
short-lived, surviving but for a few hours, and are filled with a clear 
serous fluid which may become lactescent. After accidental or spon- 
taneous rupture there is left a slightly tumid superficial excoriation, 
which is covered frequently by a light crust and at times is character- 
ized by circumscribed hyperaemia, slight infiltration, or oedema of the 
base and periphery. The lesions rarely persist for more than a few 
days, and leave no permanent pigmentation or scar, unless compli- 
cated by pus-infection. The subjective sensations are not usually 
severe ; they include moderate pain, itching, and heat. 

Herpes Facialis, Herpes Febrilis, Herpes Labialis, " Cold-sores." — 
About the lips, the mouth, the cheeks, and the aire of the nose, more 
rarely upon other portions of the face, lesions occur singly or in 
groups, possessing the characters described above. Their occurrence 
is usually sudden. Their frequency about the lips has suggested one 
of the titles under which they are most often described by authors. 
The tongue, the buccal membrane, the palate, and the larynx may 
participate in the morbid process; the lesions in such moist situations 
being represented by isolated or by grouped dark-grayish patches of 
epithelium thai are sensitive and exfoliate. The functions of the 
mouth in articulation and mastication are thus rendered painful. 
Often the lesions coalesce, forming in an irregular line of elevated 
epidermis a pea-sized bleb, spread along the vermilion border of the 
lip and distended with clear serum. The burning and itching sen- 
sations which accompany the lesions are often marked and distressing. 
In the course of two or three days thin crusts form, the exfoliation 



HERPES SIMPLEX. 371 

of which terminates the disorder. The disease is common in acute 
pneumonia and in malarial and enteric fevers. In these cases, as 
Kaposi has shown, the occurrence of the eruption by no means augurs 
favorably in every instance, as, nevertheless, a fatal result may follow. 
The connection between labial herpes and rigors has long been recog- 
nized, though particular attention has been directed to this relation 
by Hutchinson and Symonds. Trophic disturbances, traumatism, ex- 
posure to solar heat, unusual fatigue, a simple coryza, exposure to a 
draught of cold air, and temporary gastric disorders may suffice to 
induce the disease. There are patients who can produce the lesions 
at will by tickling the lips with a feather, and in some individuals 
there is an exquisite susceptibility to the disease. The disorder is 
always short-lived though often recurrent, and the superficial crusts 
which terminate the process are never followed by scars. Symmers, 
of Aberdeen, successfully cultivated a rod- or thread-shaped micro- 
organism (solid, filamentous, and without septa) obtained from the 
lymph in vesicles of herpes labialis. 

Labial herpes should not be confounded with the symptoms of La 
Perleche, described on another page. The disease to which the last 
name has been given in France is due to a parasite. 

Epidemic Herpetic Fever. — Epidemic herpetic fever, which has been 
observed by Savage 1 and others, has prevailed in institutions in which 
young subjects are congregated. There are usually rigor, high fever, 
a coated tongue, adenopathy, and a vesicular rash over the face. 

Generalized Herpes of French authors has been rarely seen in this 
country. 

Herpes Progenitalis (Herpes Genitalis, Herpes Prceputialis) is 
characterized by the appearance of one or a group of transitory 
vesicles, in men on the inner face of the prepuce, especially upon 
its upper limb, on the glans, on the balano-preputial sulcus or in the 
adjacent integument; in women, on the hood of the clitoris, the labia 
minora, the inner face of the labia majora, or adjacent surfaces even 
as far removed as the buttocks. 

The disorder is seen most frequently in young adults and in early 
middle life, its occurrence after the age of fifty being unusual. 
There is commonly a precedent pruritus or a sensation of heat, some- 
times very considerable pain, followed by the appearance of one or of 
several pinhead-sized vesicles seated upon a tumid and hypersemic 
base. Within the preputial sac the lesions may either rupture at an 
early moment or assume the features above described as presented 
upon the mucous membrane of the mouth. The resulting oedema of 
the prepuce is often displayed in an annular tumefaction encircling 
the glans, while the labia minora perceptibly project from the general 
vulvar plane. In these localities the floors of ruptured vesicles are 
particularly liable to be irritated (coitus, caustic, etc.), and then 
pus and even blood may be exuded with much angrier excoriation and 
the resulting crusts be of darker shade. In the course of a few days 
1 J. C. D., 1883, i. ; p. 253. 



372 HYPEREMIAS AND INFLAMMATIONS. 

even these crusts fall, and the disease is at an end. Successive crops 
of vesicles, however, may prolong the disorder for several weeks. 
Recurrence is common. 

Rarely, a first attack of herpes in man results in an extraordinary 
sensitiveness of the balano-preputial membrane that persists for more 
than a year. The patients are often middle-aged men, married and 
virgin as to venereal antecedents. The membrane becomes tumid, 
tense, slightly glazed and dark red to dark purple in hue. Upon any 
undue sliding of the prepuce over the glans there occurs a very super- 
ficial fissure, whence a drop of serum oozes. The membrane becomes 
so sensitive that the passage of the finger over it is resented as though 
the conjunctiva had been touched. Unusual friction by the clothing 
or the use of a stimulating lotion is followed by intense pain and ag- 
gravation of symptoms and the price of coitus is several days' rest in 
bed. 

The Diagnosis of herpes progenitalis is between chancroid and 
chancre. The latter will be manifested by its induration, its period 
of incubation, and its characteristic inguinal adenopathy. The 
chancroid, whether in pustular form or as an inoculated abrasion, is 
db origine ulcerative in tendency, capable of auto-inoculation, and 
often accompanied by sympathetic, inflammatory, or virulent bubo 
of one side. Balanitis, with its puriform secretion and superficial 
patches of reddened epithelium, is readily distinguished from herpes 
progenitalis by its symptoms, though the two disorders frequently 
coexist. 

The patient who exhibits a herpes of the genital region to-day may 
have been inoculated at the site of the lesion, which to-morrow or 
later may take on the chancrous modification. No individual with 
progenital herpes can be assured of immunity against syphilis until 
the longest period of incubation of the syphilitic chancre has elapsed 
since the date of the last suspected exposure. 

Herpes progenitalis is almost universally the result of naturally or 
unnaturally induced sexual erethism or of congestion of the genitals 
from other causes. Its occurrence in an individual virgin as to such 
antecedents may be due to the causes efficient in the production of her- 
pes facialis. In unusually sensitive persons it may be associated 
with dyspepsia, constipation, and the phenomena of the gouty state. 
It may follow any of the venereal diseases ; or may be induced simply 
by filth. Though relatively rare in chaste women, it is of common 
occurrence in prostitutes. In some women it frequently accompanies 
menstruation (Herpes Menstrudlis) . 

Diday and Doyon 1 believe that true herpes of the genital region is 
always of recurrent type, and well marked by its special course, career, 
and consequences. All others of a false type are divided by them into 
(1) an irritative form, seen in women as the result of vaginal dis- 
charges, sexual irritation, etc. ; (2) a pseudo-membranous or diphthe- 
roid form, also occurring for the most part in women, presenting vesi- 
1 Les Herpes geuitaux, Paris, 1886. 



HERPES SIMPLEX. 373 

cular and even bullous lesions the rupture of which is the signal for 
pseudo-membranous transformation; and (3) a neuralgic form, which 
is merely zoster of the genital region. 

Pathology. — The eruptive phenomena are due to irritation of the 
nerves either directly or through reflex excitation. There is in many 
(probably in all) cases a localized peripheral neuritis of brief dura- 
tion, involving the superficial nerves. The possibility of a microbic 
origin has been suggested. 

Treatment. — The milder forms of herpes occurring about the lips 
and the genitalia require the simplest treatment. Sponging with 
pure water as hot as can comfortably be tolerated is often of value if 
followed by the local application of a weak lead solution, spirit of 
camphor, or solution of zinc sulphate 1 to 6 grains (0.066-0.40) to 
the ounce (30.). Alcohol or spirit of camphor applied locally will 
sometimes abort the disease. Equal parts of tincture of benzoin, 
alcohol, and glycerin is an effective combination. Duhring recom- 
mends highly the following: 

$ Zinc, sulphat., •» -- ^-j*-:. i 33_4| 

Potass, sulphurat.,/ aa ^ J 5j ' ^^l 

Alcohol., 5jj 41 

Aquae dest., 3vij; 28| M. 

Sig. Shake and apply freely and frequently. 

Bleuler states that a 1 per cent, ointment of cocaine gives prompt 
relief and shortens the course of the disease. On the lips, after rup- 
ture of the vesicles, the abraded surface may be protected by frequent 
applications of the compound tincture of benzoin. Crusts may be 
removed by the use of simple ointments, to which tincture of benzoin, 
1 drachm (4.) to the ounce (30.), may be added with advantage. 
For lesions at some distance from the mucous surfaces, dusting-pow- 
ders sometimes give relief; or if the lesions be few in number and 
be seen before rupture of the vesicles, the latter may be sealed com- 
pletely with several layers of collodion, beneath which the lesions 
rapidly dry and disappear. 

Occurring upon the genital region, the lesions are to be protected 
by the interposition of a pledget of lint, or a borated or salicylated 
dusting-powder. As a rule, ointments are unsuited for the moist 
mucous surface of the genitals, the malodorous emanations from most 
diseases of such parts being retained by all grease-containing com- 
pounds. Lotions answer far better, and they may be made stimulant 
with alcohol; astringent with tannin, zinc sulphate, or cupric sul- 
phate ; anodyne with opium or cocaine ; and antiseptic with formalin, 
carbolic acid, or corrosive sublimate. Prophylaxis by the local use of 
aromatic wine, or tannin and brandy, with a sexual hygiene that will 
prevent congestion of the genitals, is a matter of importance. In 
cases in which recurrences continue it is necessary to investigate the 
general health of the patient and correct whatever defects may be 
found. Arsenic is occasionally of value in preventing recurrences. 



374 BTPEEJEMIAS AND INFLAMMATIONS. 

HERPES ZOSTER.* 
(Gr., Zuaryp, a girdle; Lat., cingulum, a girdle.) 

(Sjiixgles, Zoster, Zona, Ignis Sacer, Hemizona. Ger., Gurtel- 

FLECHTE, GuRTELAUSSCHLAG. Fl\, ZONA.) 

Symptoms. — The eruption in herpes zoster usually is preceded, 
for a period lasting from a few hours to days and even weeks, by hy- 
peresthesia, pruritus, and neuralgic sensations of moderate or of 
severe intensity. 2 These sensations usually are limited to the area of 
the integument subsequently or coincidently displaying cutaneous 
lesions ; but there are exceptions to this rule, as at times the pains are 
experienced elsewhere. Often, though limited to the region about to 
be attacked, the pain occurs where it is experienced in other neuralgias, 
at the points indicated by Romberg as corresponding with regions in 
which cutaneous branches are given off by the nerve-trunks. There 
may be mild constitutional disturbance in the form of malaise or 
febrile symptoms. Adenopathy occurs frequently in the neighbor- 
hood of the eruption, and may be generalized. 

The lesions of zoster in from two to a dozen or more irregularly 
shaped groups, commonly are arranged along the cutaneous distribu- 
tion of a single nerve. These groups are separated by areas of nor- 
mal integument, show little tendency to coalesce, and may be widely 
scattered. Aside from the few exceptions which prove the rule, 
zoster occurs but once in the lifetime of an individual, and is limited 
to one side of the body. 

According to Fabre, the essential lesion, always present even when 
vesicles are not seen, is the first macular efflorescence of the disease 
in the form of brilliant or dull-red, poorly defined, erythematous 
macules, groups of which appear in the tract supplied by the affected 
nerve. As the patient rarely presents himself for treatment until 
after the appearance of vesicles, the macules usually escape observa- 
tion, cither having disappeared or having been overlooked. The 
vesicles or vesico-papules which are generally regarded as more char- 
acteristic of the disease, appear afterward in from a few hours to a 
day or more, spring from the macules or from the normal skin, and 
are accompanied by a sensation of heat. These typically perfect, 
isolated vesicles vary in size from that of a grape-seed to that of a 
coffee-bean. They appear in successive groups of from eight to a 
dozen or more, which gradually increase in size and attain maturity 
simultaneously in from three to seven days. 

The lesions, when fully developed, project well from the widely 
hyperaemic base from which they spring, are tense from complete dis- 
tention, and have no tendency to spontaneous rupture so firm is their 
roof-wall. Later their early limpid contents become lactescent or 

1 For complete bibliography, see Blaschko 's article in Mrafek 's Handbuch, Bd. 
i., p. 713. 

2 Bettmann, Pruritus als Initialerscheinung des herpes zoster, Deutsche med. 
Wochenschr., 1906, Nr. 19; Cutan., abs. 1907, xxv., p. 43; lxxxvi. 



HEBPES ZOSTEB. 375 

purif orm in character. Occasionally they develop into blebs ; and may 
contain pus or blood. When abundant the vesicles may coalesce and 
form irregular patches. Involution is accomplished by desiccation 
and the formation of a yellowish-brown crust, which falls in from 
seven to ten days after the first appearance of the vesicle. New 
groups appear during a period usually of from six to twelve days, 
at the end of which time vesicles may be seen in all stages of devel- 
opment and involution. The average duration of the disease is from 
ten days to three weeks. Exceptionally, a succession of new lesions 
may prolong the disease for a month or more. 

Disappearance of the vesicles and crusts is followed often by pig- 
mentation, which may persist for weeks or months. Scarring occurs 
in some cases, especially if the vesicles have been ruptured and ex- 
posed to pus-infection. The scars left by zoster are characteristic. 
Not only are they limited to the original seat of the disease, but they 
have also a peculiar indented look, as if made by a nail-set and ham- 
mer. They are angular in outline, and do not exhibit the dead-white 
color of many cicatrices. 

The pain or hyperesthesia of zoster varies greatly in intensity and 
in duration. It is usually mild, but may be very severe, especially 
in old people. It disappears commonly with, or soon after, the ap- 
pearance of the eruption, but may persist for months or even for 
years. 

Zoster occurs chiefly in the upper part of the body, and, though 
limited to one side, this limitation is rarely observed exactly at the 
median vertical line, as a few lesions can usually be seen extending 
beyond this boundary. The young subjects of the disease are usually 
between the thirteenth and fourteenth years of life ; though children 
of five, eight, and ten years have been attacked. 1 

Atypical forms of zoster occur. The vesicles may be typical and 
few in number, possibly limited to a single group, or they may be 
abortive and transitory. Papules or vesico-papules may be the sole 
lesions. The vesicles may become transformed into pustules or bulla?, 
or be filled with blood from capillary hemorrhage, producing bluish 
or blackish lesions, known as Zoster ILemobrhagictjs, or "black 
herpes." In severe cases there may be ulceration and gangrenous or 
deep-seated phlegmonous inflammation. Keloid-like scars occur 
rarely. 

Recurrent zoster 2 is relatively rare, but more than a score of cases 
are reported in which an individual had two or more attacks either in 
the same or in different regions of the body. In many of the cases 
reported, however, the recurrent lesions were not typical of true zoster. 
Some of these are unquestionably of traumatic origin. 

Zoster of simultaneous occurrence on two sides of the body may 
foe symmetrical or asymmetrical of development. The disease in 

>B. J. D., 1905, xvii., p. 199. 

2 For a resume of the literature cf. ' ' Eecurrent Zoster, ' ' by Joseph Grindon, 
J. C. D., 1895, xiii., p. 191. Also Vomer, Annales, 1906, s. iv., vii., p. 888. 



376 HYPEREMIAS AND INFLAMMATIONS. 

either form is exceedingly rare. In our experience the anomaly is 
generally the result of herpes either in a syphilitic subject or in one 
under the influence of arsenic. T. C. Fox 1 reports a symmetrical 
case in an infant of five months. 2 

The eruption may occur over the terminal filaments of nerves 
which have no communicating branches, unless, as suggested by 
Blaschko, 3 there be an interlacing of fibres in the spinal cord. 

In explanation of the difference in the clinical symptoms of 
many recorded cases of zoster, authors have attempted to distinguish 
between the types of the " true " disease, and others produced by 
trauma, by arsenical and other medicamentous ingesta. In this way 
it has been attempted to explain not merely the epidemics of the 
disease of the kind described by Kaposi, Lange, and others, but also 
the cases apparently infectious, where as in the instances observed 
by Paggi, Pudor, .Neisser, and others one individual seems to have 
transmitted the malady to another. Thus Barensprung, Jarisch, and 
others believe that idiopathic Zona is a zosterian malady sui generis, 
and not to be confused with the traumatic and medicamentous types. 
Occasionally in the course of an acute zoster, a generalized eruption 
of vesicles occurs, 4 and this with fever, hematuria, and other signs 
by grave systemic infection. 

Anomalous nervous symptoms are : persistence of neuralgia after 
involution of the cutaneous lesions ; neuralgia of an intense and intol- 
erable severity at any period of the disease; painful anassthesia of the 
skin; paretic and paralytic phenomena with resulting muscular atro- 
phy; and, in zoster of the head, keratitis and iritis, complete de- 
struction of the ocular globe, and falling of teeth and hair. 

Observers are not in agreement as to the question whether the form 
of herpes designated as simplex and that termed zoster should be con- 
sidered as one or separate affections. Of the former opinion are the 
13 authors cited by Sachs, including the names of Barensprung, Kob- 
ner, Neisser, Finger and others whose names might be added. On 
the other side a long list of authors might be adduced, including 
Hebra, Kaposi, Unna and Neumann, who hold to the total separation 
of the two maladies. At present facts sufficient to incontestibly de- 
cide the question are wanting. Clinically, the disorders are by most 
authors definitely distinguished the one from the other. 5 

Sachs has contributed a valuable paper on the subject of the epi- 
demic of zoster observed in Breslau in 1001 (G9 cases). 

According to the regions involved the following types of zoster are 
generally recognized : 

Zoster Capilt.ttii depends upon involvement of the second 

1 B. J. D., 1898, x. ; p. 252. 

- See also Kraus, Centralbl., 1905, viii., p. 226. 

i Monatshefte, 1898, xxvii., p. 175. 

\ Beyer, Monatshefte, 1906, xlii., p. 415. 

sjSee Schamberg, Archiv, 1908, lxxxix., p. 138; J. A. M. A., 1907, xlviii., p. 746. 

"ZeitBChft. f. Heilkundc, 1906, F. 12, V. 25; Eev. Prat. d. Med. Cut. Syph. 
el Wn., Nos. 1 and 2, 1907, Jan., pp. 9 and 219, full bibliography to 1904. The 
author, however, recognizes do distinction between herpes simplex and herpes zoster. 



HERPES ZOSTEE. 377 

branch of the fifth pair of nerves, and its lesions occupy the anterior 
and posterior portions of the scalp. 

Zostee Frontalis occurs in the area supplied by the supra- 
orbital nerve, which springs from the first branch of the trigeminus. 
Its lesions extend from the upper eyelid to the vertex, and spread 
in a fan-shaped figure over one-half of the brow, forehead, and 
scalp. 

Zostee Ophthalmicus may be a severe and dangerous manifesta- 
tion of the disease, being often complicated by agonizing neuralgia, 
formidable involvement of all parts of the eye, even resulting in pan- 
ophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. 
Typical cases of zoster of this region may not, however, exhibit a 
single untoward symptom of the disease. 1 

Zostee Facialis depends upon involvement of the sensory nerve- 
fibres of the trigeminus distributed to the face, its lesions being dis- 
played over one cheek, the side of the nose, the half of the lip or of 
the chin. The facial and seventh nerves may chiefly be affected. 
Care must be taken in cases of this variety not to confound the disease 
upon the nose with acne or with painful tertiary syphilitic lesions, 
errors in diagnosis that have occurred. When the lower jaw is in- 
volved there may be severe toothache, dysphagia, and fall of the 
teeth, with great resulting deformity. 

Zostee Nucile, seu Collaeis, occupies the region extending for- 
ward from the cervical vertebra? to the clavicle, or upward toward the 
occipital region and the auricle. 

Zostee Beach ialis occupies the region from the last cervical 
and first dorsal vertebrae over the supra-spinous scapular region and 
the contiguous portions of the upper arm. Earely, even the skin of 
the fingers and that over the first and second ribs are involved. It 
is a common and usually a mild form of the disease, and is charac- 
terized by a peculiar isolation of the vesicular groups. It occurs 
also with lesions of exclusively brachial distribution. Thomson, 
of London, reports brachial zoster with involvement of the right 
internal cutaneous nerve in which two groups of vesicles appeared 
in the palm of the hand. 

Zostee Pectoealis is the most frequent form of the disease, 
from which the common name " shingles " originated. The eruption 
occurs below the first dorsal vertebra, covers the skin of the thorax 
as far as the lumbar vertebrae, and extends from the spinal column 
behind to the sternal region in front. Two, three, or more of the 
intercostal nerves in this region are commonly involved, and the 
neuralgia resulting has frequently been mistaken for the pain of 
pleurisy. Children more often display this form than any other var- 
iety of zoster. 

Zostee Abdominalis. — The area here involved extends from the 
lumbar vertebrae to the median line of the abdomen. Zoster abdomi- 

1 Osterroht, Herpes zoster ophthalmicus, Carl Marhold, Halle a. S., 1907 • 
Monatshefte, 1907, xliv., p. 46. 



378 HYPEfi.EUIAS AND INFLAMMATIONS. 

nalis is usually much less pronounced in its features, and the exan- 
them is less abundant, than in the variety of the disease just de- 
scribed. When constipation exists defecation may be attended with 
considerable pain. 

Zoster Femoraeis covers the buttocks and sacrum, and extends 
along the thighs, sweeping from behind forward and from above 
downward as far as the popliteal space; in some cases involving the 
leg and foot. The penis, the scrotum, the labia, the vestibulum 
vagina?, and peri-anal region may then exhibit unilaterally arranged 
vesicles. As this is a relatively rare manifestation of the disease, 
the diagnostician will do well to recall the possibilities in every case 
of an exanthem limited to one side of the perineum, supposed to be 
the seat of genital eczema. 

Etiology.- — Herpes zoster occurs in both sexes, and in the young 
as well as in the old, though it is rarely seen in infants. It shows a 
tendency to increase in severity with the age of the patient, especially 
after middle-life. It is influenced by the seasons, as cold and damp 
weather serves to increase its frequency in those susceptible to it. 
Frequently there is a history of recent exposure of the involved 
region to a draught of cold air. Many other depressing agencies are 
named as effective in the production of zoster. Among them are cer- 
tain poisons (carbon dioxide, belladonna, and atropine), pyemia, 
carcinoma, fever, measles, pulmonary inflammations (including 
phthisis), septicaemia, hemorrhages, traumatism, malaria 1 puerperal 
eclampsia 2 and spinal injections. 3 It also has followed vaccina- 
tion, the passage of electrical currents, the extraction of teeth, an 
accidental prick by a thorn, the tapping of hydatids, and gunshot- 
wounds of the body. Curtin 4 reports ten cases in which zoster ac- 
companied inflammation of serous membranes. Inasmuch as no one of 
these causes can be cited as certainly effective in all cases, it can 
merely be said that any influence sufficient to induce inflammation of 
a sensory nerve or its ganglion may be followed by the objective signs 
of the disease. 5 In numerous instances zoster has followed a pro- 
longed course of arsenic. Occasionally zoster occurs in epidemics, 
or coexists with other epidemic disorders, such as influenza and vari- 
cella. 6 The evidences of direct contagion in a few instances are very 
strong. These facts, and the rarity with which zoster recurs in the 
same individual, together with the adenopathy which is often present 
at the beginning of an attack, favor the growing belief that zoster is, 
in -Mine instances at least, an infectious disease. 7 

1 Cf. Winfield, N. Y. Med. Jour., 1902, lxxvi., p. 191. 

2 Archiv, 1907, lxxxiii., p. 147. 

'Pantner and Simon, Annales, 1908, s. iv., ix., p. 124. 

4 Amer. Jour. Med. Sci., 1902, cxxiii., p. 264. 

8 Seventeen observations of arsenical zoster are cited by Sachs (1. c.) ; three 
produced by carbonic oxid, and the others by absorption of morphia, cocaine, cor- 
rosive sublimate, and antipyrine. 

•Corlett, J. C. D., 1905, xxiii., p. 289. 

'Hay presents an excellent argument in favor of the infectiousness of zoster, 
and gives references to literature on the subject. J. C. D., 1898, xvi., p. 1. 



EEBPES ZOSTER. 379 

Pathology. — In some cases there is unmistakable evidence of a 
descending interstitial neuritis, but the affection may be associated 
with irritative action in any portion of the nervous tract from central 
to peripheral limit. The researches of Barensprung, Rayer, Wagner, 
Charcot, Kaposi, and others have demonstrated with sufficient clear- 
ness that in zoster there are always pathological changes at some 
point in the corresponding nervous tract (cerebral or spinal centres, 
ganglia, or the nerves themselves). In the majority of cases in which 
a pathological lesion is demonstrated there is found an interstitial 
neuritis of the posterior ganglion or of the posterior spinal root, but 
neuritis and perineuritis of the peripheral nerves, without change in 
the more centrally situated parts of the nervous system, are reported 
by competent observers. In a number of cases multiple neuromata 
have been discovered along the aifected nerve, the spinal cord and 
ganglia remaining normal. In other instances the irritation of the 
nerve-tract has been due to hemorrhage, degeneration, or pressure 
from tumors, etc. 

Head and Campbell 1 have been able to make post-mortem exami- 
nations in twenty-one cases. They found inflammatory and sec- 
ondary degenerative changes not only in the ganglia of the posterior 
roots, but also in the posterior roots themselves, in the root-fibres of 
the posterior columns, and in the peripheral nerves. Reflex irrita- 
tion seems to have been an effective cause in a few cases. 

According to Biesiadecki and Haight, the cutaneous lesions orig- 
inate in the deeper portions of the rete, precisely as in other vesicular 
disases. The exudate from the hypersemic corium, especially its 
papillary layer, presses upward into the rete, the epithelia of which 
are thus separated and vertically elongated, the lacunae between them 
being distended with serum and a few round cells. Often the vesi- 
cles form about the hair-sacs. As the exudation increases the rete- 
cells are progressively separated, and finally are discovered free in 
the exuded fluid, though some, in changed form but still united to 
each other, may be found in the upper part of the vesicle. Except at 
the margin, the mucous and horny layers are separated by the exuda- 
tion. At first many-chambered, with delicate, easily ruptured parti- 
tions, the vesicle represents finally a single chamber filled with serum 
containing rete-cells and a few pus-cells, the latter increasing in num- 
ber as the vesicle changes its type. Its base at first rests upon the 
lower portion of the mucous layer ; later, upon the corium itself, in 
which all signs of papilla? are absent. In the vicinity of the vesicle 
the papillae and corium are infiltrated and the vessels are dilated, 
but these inflammatory changes do not extend far into the corium. 
The deep location of the vesicle, resting as it does upon the papillary 
layer, accounts for occasional destruction of the papillae and conse- 
quent scarring. 

The vesicle of zoster (and to a less degree that of variola and of 
varicella) is peculiar in that it contains in the deeper portion and 
1 Brain, 1903, xxiii., p. 362 (monograph, well illustrated). 



380 HYPEREMIAS AND INFLAMMATIONS. 

along the walls epithelial cells which have undergone transformation 
into round or ovoid globular bodies, usually larger than the normal 
cells, which have apparently a limiting membrane or double-contoured 
wall, and contain from two to a dozen or more rounded bodies. 
These transformed epithelial cells have been described as protozoa, 
but their true nature has been demonstrated by Unna, Gilchrist, 1 and 
others. Other varied and extraordinary figures are seen. Among 
them are rings with fragmentary edges and swollen centres (the edge 
representing a homogenized and fibrinously degenerated protoplasm; 
the centre a homogenized nucleus). Elsewhere are thin and ex- 
panded shells filled with epithelial nuclei. Irregularly " ballooning " 
balls, baskets, tubes, hanging cords, and other odd forms take the place 
of the trabecular found in other vesicles. Unna names this peculiar 
change in the epithelial cells a " ballooning degeneration," to dis- 
tinguish it from the reticulating forms. Kopytowski 2 states that 
these forms are due to an oedematous degeneration (views based 
on an examination of sixteen cases). Pollitzer 3 reports an unusual 
case in which the vesicles were limited to the rete Malpighii of the 
hair-follicles. 

Diagnosis. — The vesicles of herpes zoster are not rarely con- 
founded with those of eczema ; but the distinction between the two is 
always readily established. In eczema there is itching but no neu- 
ralgia; the vesicles tend to rupture spontaneously and never persist 
as they do in zoster ; eczematous lesions are also smaller, more acumi- 
nate, and rarely distinctly limited to the lateral half of the body. 
Herpes simplex is frequently recurrent, herpes zoster rarely; herpes 
simplex is exceedingly liable to spread around the mucous outlets 
of the body, and on either side of the latter, while zoster reaches 
such regions only after extension from other parts, and is then almost 
invariably monolateral. Its lesions are, moreover, never grouped 
in the concentric circles of herpes iris. 

Treatment. — The purpose of local treatment of herpes zoster is to 
protect the vesicles from rupture and infection, and to relieve pain. 
These ends are best accomplished by thickly dusting the lesions with 
an anodyne powder, such as Anderson's powder, containing morphine 
sulphate, 2 grains (0.133) to the ounce (30.) ; lycopodium with pow- 
dered opium, orthoform, and boric acid, or zinc stearate with acetani- 
lid, etc. The vesicles may be punctured with an aseptic needle and 
the contents evacuated, but rupture of the lesions should not be per- 
mitted. Over the entire affected surface should be laid gently a sheet 
of soft lint or of antiseptic cotton, its meshes being also filled with the 
powder, and a bandage, when practicable, smoothly bound over the 
whole. In the milder cases nothing more than this treatment is 
needed from first to last. Collodion and the glycogelatins furnish 
■a convenient and effective dressing if the contents of the vesicles be 

'Johns Hopkins Hosp. Rep., 1896, vii., p. 138. 
2 Archiv, 1900, liv., p. 17. 
8 J. C. D., 1903, xxi., p. 73. 



HERPES ZOSTER. 381 

first evacuated and the surface rendered as nearly aseptic as possible. 
In cases in which the lesions have ruptured and their bases have un- 
dergone erosive or ulcerative changes, oleated lime-water with zinc 
oxide, belladonna, and opium or morphine should be applied, and be 
covered with Lister protective. Carbolated and anodyne ointments 
may also be used, especially toward the conclusion of the case. Bleu- 
ler 1 states that applications of 1 part of cocaine in 50 parts each of 
lanolin and vaselin not only relieve the pain, but also shorten the dura- 
tion of the disease. 

Lotions of carbolic acid and glycerin ( 1 part to 6 ) , or lead-water 
and laudanum, or the " lead-and-opium wash " may be employed. 
Van Harlingen recommends | ounce (15.) each of precipitated zinc 
carbonate, powdered zinc oxide, powdered starch, and glycerin, shaken 
up in £ pint (240.) of water. 

Duhring speaks well of collodion with morphine, in the strength of 
10 grains (0.66) to the ounce (30.). Kaposi warns against the use 
of diachylon ointment. Generally, it may be said that ointments 
should be the last resort, but those containing from 10 to 20 grains 
(0.66-1.33) of the aqueous extract of opium or of belladonna to the 
ounce (30.), or a 5 per cent, cocaine salve, will at times give relief 
from pain. The oleate of cocaine and menthol have been used locally 
with great advantage in meeting the same indication. Alcohol ; or re- 
sorcin 2 parts, alcohol 100 parts ; or 1 per cent, alcoholic solutions of 
menthol or of thymol, may be useful when other measures fail, and 
it is claimed by some that these remedies will abort the disease if used 
early. A continuous galvanic current of between two and three mil- 
liamperes may be applied over the root of the nerve two or three 
times daily for ten minutes at a sitting ; or the high frequency current 
over the nervous centre responsible for the disease, or spraying with 
ethyl chlorid. 2 Blistering or dry-cupping, or in sthenic cases wet- 
cupping, may be employed instead of electricity. 

]STo remedy for internal use is known to have the power of abort- 
ing or of shortening an attack. Quinine is certainly indicated and 
does no harm, but quinine and strychnine in full doses have alike 
proved inefficacious. Other remedies employed are zinc phosphide 
in i grain (0.022) doses, repeated every three hours, and, if indi- 
cated, in combination with i (0.011) grain of the extract of nux 
vomica; arsenic (Kaposi); and the tonics in general. Anodynes, 
by mouth or by hypodermatic injection, are often indispensable. In- 
asmuch as many patients consider the attack a trivial matter, it is of 
some consequence that they be warned of the possibilities of the future 
and that they be confined to an apartment of equable temperature 
in which they are not exposed to atmospheric changes. This measure 
is of special importance in the zosters of the face. A skilled oculist 
should be consulted in cases involving the eye. 

1 Neurologisches Centralblatt, 1899, xviii., p. 1010. 

2 A. Gregor-Penryn, Brit. Med. Jour., 1905, xli., p. 651. Morrow, J. C. D., 
1905, xxiii., p. 157. 



382 HYPEREMIAS AND INFLAMMATIONS. 

Prognosis. — Zoster usually runs a benign and self-limited course. 
The prognosis in exceptional eases may be in the highest degree grave. 
Many severe eases have occurred in which patients, after years of 
intense suffering, have resumed the occupations of life, physical 
wrecks of their former selves, their faces indented with scars, and the 
vision of one eye impaired or ruined. Rarely the termination is 
fatal. 

DERMATITIS HERPETIFORMIS. 1 

(Herpes Oircinatis T5ii.lostjs [E. Wilson], Herpes Gestationis 
| Milton, Bulkley, and others], Pemphigus [Klein], Pemphigus 
Circinatis [Raver], Herpes Pheyct.enoides [Gibert], Herpes 
Iris [Jarisch], Fatal Pemphigus-like Dermatitis [Mayer], 
Peculiar Skin-eruption recurring during Pregnancy 
[Oswald], Bullous Eruption of a Peculiar Character 
[Leigh], Hydroa [Jones and Bulkley], Duiiring/s Disease, 
Hydroa Herpetiformis. Ft., Maladie de Duhring, Derma- 
tite PoLYMORRiiE [Brocq], Pemphigus compose [Devergie], 
Pemphigus aigu prurigineux [Chausit], Pemphigus prurigi- 
neux [Hardy].) 

Dermatitis herpetiformis is a somewhat rare cutaneous affection, 
commonly subacute or chronic in career, at times with systemic dis- 
turbance of a mild or serious type, characterized by the production 
upon the skin, of vesicles, pustules, blebs, or papules, often in multi- 
form combination, usually grouped, often accompanied by pigmenta- 
tion, producing excessive pruritic and burning sensations, frequently 
recurrent, and rebellious to treatment. 

Dermatitis herpetiformis is a malady which, in one form or an- 
other and under different titles has long been recognized and de- 
scribed. The credit, however, of clearly establishing its identity, 

'Duhring: "Dermatitis Herpetiformis; its Relation to So-called Impetigo Her- 
petiformis," Amer. Jour. Med. Sci., October, 1884. "Dermatitis Herpetiformis; 
Case of, Caused by Nervous Shock," etc., ibid., January, 1885. "Case of Derma- 
titis Herpetiformis, Illustrating the Pustular Variety of the Disease," J. C. D., i., 
No. 8. ' ' Case of Dermatitis Herpetiformis with Peculiar Gelatinous Lesions, ' ' 
Med. News, March 7, 1885. "Notes of a Case of Dermatitis Herpetiformis," etc., 
N. Y. Med. Jour., November, 1884. "A Case of Dermatitis Herpetiformis (Bul- 
losa)," ibid., July, 1884. Cf. Duhring, p. 436. See also: Unna, Monatshefte, 1889, 
ix., p. 97. Brocq, Annales, 1888, s. ii., ix., pp. 1, 65, 133, 209, 305, 433, 493. 
Gaucher et Barbc, Annales, 1896, s. iii., vii., p. 64. Corlett, Recurrent bullous erup- 
tion limited to certain areas, Tr. Amer. Derm. Ass., May 31, 1898. Tenneson- 
Lyon, Annales, INKS, s. ii., ix., p. 328. Darier, Annales, 1896, s. iii., vii., p. 842. 
ThUhez, These de Paris, 1895. Kromayer, Derm. Zeitschr., July, 1897, p. 475. 
Leredde, Annales, 1895, s. iii., vi., pp. 281, 369, and 1896, s. iii., vii., p. 846. 
Triboulet, Id., 1892, s. iii., iii., p. 272. Radcliffe-Crocker, Brit, Med. Jour., May 
22, 1886, p. 966. Diseases of the Skin, 1898. Dubreuilh, Annales, 1892, s. iii., 
iii., pp. 50 and 353. Jamieson, Dermatitis herpetiformis, B. J. D., March, 1898, 
p. 75. Fordyce, .1. C. Gen.-Urin. D., Nov., 1897. Bulkley, American Jour, of 
Obst., Feb., 1874, vi., p. 580. Fox, Archiv, 1880, vi., p. 16. Duhring, The 
Medical News, July 19, 1884. Founder, Bull. Medical, 1892, p. 1179. Melot, 
These de Paris, Dec. 19, 1894. Chas. Perrin, These de Paris, 1895, p. 59. Bar 
and Tissier, Bull, et Mem. de la Soc. Obstetr. et Gynecol, do Paris, Feb., 1895. 



DEEM AT IT IS HERPETIFORMIS. 383 

and of recognizing one process as differently described in the several 
observations of others, is due to Duhring, of Philadelphia. 

Symptoms. — Constitutional symptoms may be slight or wanting 
but the first appearance of the disease and the succeeding attacks or 
exacerbations frequently are announced by malaise, sensations of 
chilliness, decided rigors, or alternations of cold and hot sensations, 
with systemic disturbances. The skin usually is the seat of pruritic 
or of burning sensations, followed in the course of from twelve hours 
to two days by the appearance of the exanthem, which may be macular, 
papular, tubercular, vesicular, pustular, or bullous in type, very rarely 
purpuric ; or multiform combinations of these lesions may recur ' in 
every variation. The lesions may be cutaneous, muco-cutaneous, or 
mucous in situation, and often are disposed symmetrically. 

The macular form of eruption appears in small-coin- to palm-sized 
patches, irregularly rounded, coalescing, well or ill defined as to out- 
line, and slightly raised, suggesting the lesions of erythema multi- 
forme or urticaria. Often there are formed infiltrated areas of a 
vividly red hue on which other lesions are developed. Imperfectly 
defined maculo-papules, papules, and papulo-tuberculous lesions, vary- 
ing in shape, size, and firmness, may also spring from or be inter- 
mingled with the reddish maculations described above. 

In typical development, however, the disease presents vesicular 
symptoms of herpetic type. Flat, slightly elevated, hard, angular, 
irregularly outlined vesicles may appear, pinhead- to bean-sized, and 
tensely distended. They may be pale yellow or darker in color and 
without or without areolae. When bullae form they may be sparse or 
be plentiful, and be bean- to egg-sized, with cloudy, lactescent, hemor- 
rhagic, or purulent contents. Pustules when present are single or are 
clustered, pinhead- to bean-sized lesions, flat, each surrounded by a 
livid areola. 1 When evolution is complete, segments of rings, or dis- 
tinct rings, of new minute or large pustules surround those first 
formed, and in less than a week these rupture and become covered 
with a crust, which is flat, adherent, and yellowish, greenish, brownish 
or blackish in color. When there is coalescence a large coin-sized 
pustule and crust may result, and even extensive patches of these 
coalesced lesions may form. The lesions may number from a score 
or fewer to hundreds. A portion or all of the cutaneous surface may 
be involved. 

The imprint of the cutaneous symptoms is multiformity, recur- 
rence, and variation in type from one efflorescence to another. Vesi- 
cles, pustules, and bullae without order or regularity of evolution or of 
recurrence appear at one and the same time, in rapid or in slow 
succession, and, without fixed intervals of appearance, for months 
at a time. Generally, however, a prevalence of one special type of 
lesions may be noted during a single period of outbreak or of re- 
currence. This prevalence is in the direction generally of lesions of 

1 Cf. Wende and Pease, ' ' A Case of Dermatitis Herpetiformis, Illustrating an 
Unusual Pustular Variety of the Disease," J. C. D., 1901, xix., p. 171. 



384 HYPEREMIAS AND INFLAMMATIONS. 

an herpetic type, viz., the vesicular and the bullous in groups, though 
less frequently one of the other types may predominate, and rarely 
vesicles may be absent. The surface may be invaded partially or 
generally ; often only the trunk and extremities are involved. Occa- 
sionally vesicles and blebs are tilled with blood. 

As a result of the conditions described above a peripheral new for- 
mation of lesions tends to produce marginate patches in which group- 
ing occurs, the groups, however, being interspersed with diffusely dis- 
seminated lesions of various types. The irregular, angular, or stel- 
late forms of the lesions containing fluid are highly suggestive. Pig- 
mentation and infiltration of the skin are commonly noticed. The 
subjective sensations of burning increase and diminish as cutaneous 
lesions are multiplying or are disappearing. The pruritus is in some 
cases more severe than in eczema, and the traumatisms of scratching 
add greatly to the multiform features of the disease. 

The disease lasts for months and even for years. Duhring reports 
cases lasting from five to fifteen years, with periods of relative or of 
entire immunity. In one of Duhring's cases there were thumb-nail- 
sized, raised but flat, golden-yellow-colored lesions, of firm consistency, 
containing a similarly colored, thick, consistent, gelatinous pulp ; 
these features have been noted in other instances. 

When the oral cavity is invaded there appear upon the sodden 
and macerated mucous surface pustules and bullae, which rupture, 
leaving raw and unhealthy-looking erosions, even sloughing patches 
of mucous membrane. Crusts form about the nares and the lips, and 
the stench from the patient is intolerable. In the same way the 
vulva, the anus, and the prepuce may be surrounded by vesicular and 
bullous lesions, which form also on the mucous surfaces adjacent and 
pursue a course similar to that recognized in the mouth. 

In grave cases, as the skin symptoms exhibit a marked aggrava- 
tion the systemic condition changes for the worse. Crusting, lym- 
phangitis, adenopathy, lichenification may be the results of scratching 
and secondary infection of the skin. After a low fever alternating 
with chills and accompanied by progressive cachexia and emaciation, 
an intermittent diarrhoea or a pneumonia may close the scene. The 
repulsive appearance of the patient at the last, in severe cases, is as 
formidable as in fatal cases of confluent variola or of severe pityriasis 
rubra. 

Complications of all forms of dermatitis herpetiformis are: the 
involvement of the nails, which may be shed ; the occurrence of scars 
only after secondary infection of lesions and ulceration ; vegetations, 
as in pemphigus vegetans; marked cachexia; and, lastly, serious dis- 
turbance of the nervous system in consequence of long-continued 
anxiety as to the health and distress produced by the eruptive symp- 
toms. 

Etiology. — The disease occurs in both sexes and at all ages, but 
somewhat more commonly after adult years have been attained; often 
in individuals of neurasthenic type or in those in whom the nervous 



PLATE X 




Dermatitis Herpetiformis. 



DERMATITIS HERPETIFORMIS. 385 

system has been subjected to unusual strain. Mental crisis, nervous 
shock, fright, anger, menstrual irregularities, pregnancy, the puer- 
peral state, septicaemia, phimosis, physical fatigue, exposure to cold, 
and defective renal excretion have all been cited as causes of the 
malady. It is possible the irritation of the nervous system may be 
due in every case to a toxaemia, but by many the disease is considered 
purely a neurosis. 

Pathology. — Histological examination shows an acute inflamma- 
tion in the upper part of the corium, chiefly in the papillary layer. 
There are dilatation of the vessels, diapedesis, marked oedema with 
infiltration of the lymph-spaces, and some plasma-cells. The vesicles 
are formed rapidly as a rule between the basal layer of the rete and 
the papillary body. Larger vesicles are formed frequently by the con- 
fluence of smaller ones, and they all are filled more or less with a 
fine or coarse network of fibrin containing polymorphonuclear with 
some mono-nuclear and eosinophile cells, red blood- and epithelial cells 
and also coagulated albumin. The eosinophiles are found in the vesi- 
cles and in the blood-vessels and lymph-spaces of the corium, and 
frequently between the epithelial cells. The deeper portion of the 
corium is unchanged for the most part. Eosinophilia is present as a 
rule, but its exact significance is not established, as it is found in 
other conditions. Lerrede 1 would include in this category, on the 
basis of the pathological anatomy of the disease, the pemphigus vege- 
tans of Neumann. 2 

Diagnosis. — The diagnosis in classical cases is made readily; in 
others the distinction between dermatitis herpetiformis, impetigo her- 
petiformis, and certain forms of pemphigus is exceedingly difficult. 
It is possible that between the three there may be transitional forms 
scarcely to be assigned to the one category or the other. The same is 
true of certain exceptional varieties of erythema multiforme. In 
pemphigus, as a rule, the lesions are more uniformly larger and rarely 
beset with small vesicles and pustules. The itching is less promi- 
nently a feature of the disease. 

The diagnostic features of the disease are: chronicity, with or 
without remissions or intermissions ; multiformity of the lesions, 
among which those of herpetic type usually predominate; the ten- 
dency of the lesions to appear in groups or patches ; the very marked 
capriciousness and variableness of the recurrences and exacerbations 
in their times of appearing, and in the nature, extent, and severity 
of the lesions ; itching, often intense ; and more or less pigmentation. 

Treatment. — Internal treatment has been directed to meet the indi- 
cations presented. Of great importance are hygienic measures with 
a view to maintaining the patient's general health. All excesses, 

1 Annales, 1899, s. iii., x., p. 836. Monatshefte, 1898, xxvii., p. 581. 

2 For a full discussion of the relation of this disease to allied vesicular and 
bullous dermatoses, cf. articles by Jamieson, B. J. D., 1898, x., pp. 73 and 118; 
Brocq, Annales, 1898, s. iii., ix v pp. 849 and 945; and his valuable and amply- 
illustrated chapter in La Prat. Dermat., Paris, 1900, t. i., p. 651; and Lerrede, 
Monatshefte, 1898, xxvii., p. 381. 

25 



386 BYPERMMIAS AND INFLAMMATIONS. 

excitement, and everything tending to interfere with the equilibrium 
of the nervous system should be avoided. A nutritious but simple 
diet, regular habits of living, with sufficient outdoor life and exer- 
cise, are all of great value. Medication is directed chiefly toward 
improving the tone of the nervous system, for which purposes 
strychnine, quinine, iron, small doses of arsenic, and phosphorus may 
be used. Preparations of malt and cod-liver oil are often indicated. 
Mild laxatives, and the free drinking of water between meals and 
before meals, are of value in aiding elimination. For the same 
purpose small doses of mercurous iodide may be continued for weeks 
at a time. Stelwagon has found general galvanization of value in 
one or two patients. In exceptional cases arsenic in full doses acts 
almost as a specific; it is of most value in vesicular and bullous 
eruptions. It should be remembered that when arsenic is not suited 
to a given case large doses of the drug may do much harm. Crocker 
prefers salicin in 15 grain (1.) doses. 

Other existing disturbances of the general economy due to rheu- 
matic tendencies, kidney-disease, indigestion, constipation, or other 
cause should be recognized and properly be treated. 

Locally treatment is directed to keeping the surface clean and 
aseptic, and to making the patient comfortable. Duhring recom- 
mends stimulating applications when they are well tolerated, but in 
many cases soothing and sedative preparations are necessary. 
Among the stimulating applications which have proved of value 
may be mentioned lotions and oils containing tar, carbolic acid (1 to 
20 per cent.), ichthyol (2 to 10 per cent.), and thymol (1 to 5 
grains (0.06-0.33) to the ounce (30.). Stelwagon recommends 
liquor carbonis detergens in strength varying from 1 to 10 parts of 
water up to the pure solution. Duhring found weak sulphur oint- 
ments (2 grains (0.13) to the ounce (30.)) of value in cases in 
which there were vesicular, pustular, and bullous lesions. This 
ointment should not be rubbed in vigorously, but should be tried on a 
small surface at a time for fear of inducing irritation. 

In most cases a soothing treatment is demanded by means of alka- 
line, bran-, or other demulcent baths, followed by some of the dust- 
ing-powders or the lotions advised for use in the acute stages of 
eczema. Ointments are not indicated, as a rule, but in a few cases 
diachylon ointment (Hebra), Lassar paste, zinc, mercurial, and other 
pastes and ointments have been used to advantage. For relief from 
itching camphor and chloral (1 to 5 per cent.) in oils or ointments 
may be employed. Many patients are treated with very great com- 
fort to the end in the continuous warm water-bath. 

Prognosis. — The prognosis is always doubtful, and may be at 
times grave. Temporary recovery from repeated outbreaks is com- 
mon. Persistence for years with periods of aggravation and decline 
is the rule. Brilliant recoveries, however, occur under skilful treat- 
ment. 



EYDBOA BULLEUX. 387 

DERMATITIS HERPETIFORMIS IN CHILDREN. 

Knowles 1 has made a careful study of the records of fifty-seven cases 
of dermatitis herpetiformis reported by 41 different authors, with 
results summarized as follows: Predisposing causes are (with an 
inherited or acquired neurotic tendency and weakened resistance) 
debility resulting from the exanthemata, sepsis, toxines, visceral dis- 
orders, and undue exposure — these seemed operative in about one 
half of all cases — the most occurring in male subjects. The number 
of cases diminished in very early years. Prodromata were absent 
or mild; the lesions most often were vesico-bullous, usually general- 
ized, the face and extremities being most often involved. Curiously 
at variance with symptoms in the adult was the absence of grouping 
of lesions, which were rarely pruritic, and were seldom followed 
by pigmentation. The prognosis was not grave. 

HERPES GESTATIONIS. 

(Pemphigus Hystericus. Fr., Deematite Poeymoephe douleu- 

EEUSE EECIDIVANTE DE LA GEOSSESSE.) 

The special form of dermatitis herpetiformis occurring in preg- 
nancy does not differ in its general features from the types of the 
disease seen in non-pregnant women and in men ; but there can be no 
question that the pregnant condition in many cases bears close rela- 
tion to the eruptive phenomena. The eruption often accompanied 
by febrile accesses may develop after the conclusion of pregnancy, 
but more often from the third to the fourth week after conception. 
Vesicles, blebs, papules, macules have been observed repeatedly in 
successive pregnancies of the same woman and in that subject at 
no other time. The lesions in these cases are exceedingly pruritic; 
often are developed symmetrically over large areas of the surface, 
usually more abundantly over the lower limbs ; and may be relieved 
completely before the termination of gestation, or only at that period. 
In a few instances both death of the foetus and persistence of the 
disease after delivery have been reported. The child may be born 
into the world in a condition of sound health, though the nervous 
system of the mother commonly is affected profoundly during and 
often for some time prior to the occurrence of pregnancy. 

HYDROA BULLEUX 

is a rare pruriginous form of the same disorder which may be ac- 
companied by a febrile movement. The eruption develops with 
vesicles of medium size, which later increase and multiply, become 
slightly umbilicated, desiccate, and are covered with crusts of variable 
size and color according to whether there has or has not been second- 
ary infection as a result of the scratching. The eruptive elements 

1 J, C, D. ? 1907, xxv., p. 247 (with 48 references to, literature), 



388 HYPEF^MIAS AND INFLAMMATIONS. 

appear in crops accomplishing cycles of evolution and may be general- 
ized extensively, even invading the palms and soles. 

IMPETIGO HERPETIFORMIS. 1 

(Herpes Py.emicus.) 

This is a rare inflammatory affection of the skin occurring for the 
most part in pregnant women, characterized by the development of 
smaller and larger pustules in groups and productive of grave sys- 
temic disturbance, often terminating fatally. Knowledge of this dis- 
ease is limited to the reports of less than a score of cases observed by 
Hebra and Kaposi in the Vienna clinic, and of a few scattered cases 
reported by others, including, in America, Heitzmann, Fordyce, 
Whitehouse, and Hartzell. Of the Vienna patients, twelve were 
women, and the most of these were in the puerperal state. Gunsett 
gives abstracts of twenty-eight cases : nineteen puerperal women, eight 
men, one non-pregnant woman. 

Symptoms.- — Erythematous macules followed by pinhead-sized 
pustules, usually closely set in groups, filled with an opaque or a 
yellowish-green fluid, are discovered upon the surface of the groins, 
the navel, the axilla?, the breasts, the thighs, and other portions of 
the body. A dirty brownish-colored crust is formed by rupture or 
desiccation of these lesions, and about this crust single, double, or 
triple concentric circlets of new and similar lesions appear in suc- 
cession, each series undergoing a similar process of involution. The 
eruption thus extends until the circlets from different foci of origin 
unite, and extensive areas of the skin are involved. Beneath the 
crusts the skin is reddened, infiltrated, smooth, and covered with a 
new epidermis, moist as in eczema or exhibiting a denuded corium. 
There is no ulceration. In the course of three or four months the 
eruption is well-nigh universal, the skin being swollen, shining, and 
crust-covered, or seamed with excoriations surrounded by circles of 
pustules. Exceptionally there are multiformity of lesions and the oc- 
currence of the disease in women who are not pregnant. The lingual 
mucous membrane exhibits grayish, centrally depressed patches, well 
defined in contour. Alternate rigors and febrile accesses mark the 
periods of recrudescence when new pustules form. The physical 
prostration is usually grave. Delivery seems to have no favorable 
effect upon the course of the disease in pregnant women. An endo- 
metritis with peritonitis was discovered post mortem in a single 
case. Two women only of the thirteen Vienna patients survived ; 

'Literature: Hebra, "Wien. klin. Wochenschrft., 1872, 48. Kaposi, Viert. f. 
Derm. u. Syph., 1887, 275. Dubreuilh, Annales, 1892; see also La Prat. Derm., ii., 
1901, p. 91*5. Breier, Derm. Zeit., 1894, i., p. 199. Dauber, Archiv, 1894, xxviii., 
p. 265. Borzeki, Ibid., lxxvii., p. 403; Annales, 1906, s. iv., vii., p. 304. Hartzell. 
J. C. and G. Ur. Dis., 1897, p. 506. Jamieson, Atlas Int., pi. xxviii. Tommassoli, 
Archiv, 1898, xlvi., p. 197. Zeislcr, Monatshefte, 1887, vi., p. 950. Fordyce, J. C. 
D., 1897, xv., p. 495. Sabolotsky, Monatshefte, 1895, xxi., p. 645, Kren (Riebl's 
Clinic), Ibid,, 1907, xlv., pp. 297, 300, 



IMPETIGO HERPETIFORMIS. 389 

one suffered from a relapse after several weeks of improvement. Of 
a total of 34 observations collated by Borgester there were 19 fatal 
cases. 

Etiology and Pathology. — The etiology and pathology of the dis- 
ease are necessarily obscure, having in view the relatively small num- 
ber of reported cases. The relation between this rare disorder and 
herpes gestationis, dermatitis herpetiformis, and miliary and vegeta- 
ting forms of pemphigus is not determined. Some of the reported 
instances of the disease are not regarded as strictly assignable to the 
affection first studied in Vienna. In an interesting contribution to 
this subject, Kren calls attention to the sharp distinction between the 
Hebra type of impetigo herpetiformis and the other diseases named 
above from which it is to be distinguished. In two patients shown 
by him to the Vienna Dermatological Society, a panaritium seems to 
have been the starting point of the septic process — in one case, a 
panaritium formed on the left middle-finger, in another, a pustule on 
the big toe of the right foot antedated the febrile process. 

Dumesnil, Marx, and Dubreuilh have examined the skin removed 
from living subjects of the disease, and have discovered dilatation 
of the blood- and lymph-vessels with swollen endothelium and embry- 
onic cells surrounding these, especially in the papillary body at the 
base of the pustules. Cocci were present in the pustules, which are 
always within the epidermis, and there was acanthosis of the palisade- 
layer of prickle cells. Post-mortem evidences of nephritis, endo- 
metritis, and pulmonary tuberculosis have been recognized in dif- 
ferent cases. 

Diagnosis. — The diagnosis of the disease is between herpes, 
dermatitis herpetiformis, and pemphigus. 

In herpes the purely vesicular character of the lesions and the cyc- 
lical career of the disease indicate its nature. In dermatitis herpeti- 
formis there is commonly a distinct multiformity of lesions, and the 
subjects of the disorder are not, in such great preponderance, preg- 
nant women. In pemphigus the size of the bullae and their distribu- 
tion in other than concentric groups will indicate the character of the 
disease. Special care should be taken to distinguish impetigo herpeti- 
formis from pemphigus vegetans. The locality primarily invaded is 
the same in both diseases. For details consult the paragraphs de- 
voted to the malady last named. 

Treatment. — The treatment is conducted on general principles, 
including the administration of antipyretics, and the local employ- 
ment of alkaline or of carbolated baths ; starch and other dusting-pow- 
ders; anodyne, carbolated, or simple salves; and coal-tar. The uterus 
should be relieved of its contents. Some of the recoveries followed 
treatment by continuous immersion. 

Prognosis. — The prognosis is necessarily grave. Nearly one half 
of those attacked perish. 



390 HYPEREMIAS AND INFLAMMATIONS. 

PEMPHIGUS. 1 

(Gr., -■..,, i. a b ladder.) 
(POMPHOLTX. Gcr., Bi.asi EITAUSSC 111. AG.) 

Pemphigus is an acute or chronic affection of the skin, character- 
ized by t lie formation of one or several well-defined, oval, roundel 
blebs, elevated or not above the level of the general surface, which 
may or may not be associated with systemic symptoms, the lesions 
developing in successive cycles of eruption. 

With reaped to the question whether pemphigus should be re- 
garded as the name of a distinct disease or of a group of several 
diseases, various opinions are held. At one time every dermatosis 
displaying blebs was accounted a form of pemphigus. With increas- 
ing knowledge there has been a greater reluctance to distinguish any 
disease by this specific term alone merely because of the presence of a 
bullous exanthem, and as a result a number of affections exhibiting 
bullous efflorescence upon the cutaneous surface have been wholly 
disassociated from both pemphigus and what the French term the 
" pemphigoid eruptions.'' For some authors there is only a chronic 
pemphigus ; for others, in order to establish a diagnosis of pemphigus, 
the existing lesions should repose directly upon the skin without ex- 
hibiting a peripheral inflammatory areola, or at least be the expres- 
sion of a disease with periodic exacerbations in a determined career. 

In many morbid conditions of the skin bullae are present, when 
it is manifestly improper to call the disease pemphigus. For exam- 
ple, these lesions are exhibited typically in some forms of lepra, in 
inherited syphilis, often as a result of the traumatisms of insects 
and of several infective processes. To assert that a disease is a pem- 
phigus in one of its varieties, it is necessary to recognize the presence 
of other symptoms than bulke. 

Symptoms. — The distinctions respecting the bullous dermatoses 
established by Brocq are worthy of recognition. In a first class are 
included, as suggested above, the bullae which are epiphenomena of 
some malady (e. g., erysipelas). In a second class the bulke are 
either the main feature or one of the main features of a disease. The 
second class includes both the dermatoses in which the eruptive symp- 
toms are riol commonly of bullous t\ pe, bul which become such under 
special conditions (e. g., polymorphous erythema bullosum), and 
those eruptions to which the term pemphigus is assigned by the best 
authors. 

It is to this second class, and to the last-named subdivision of the 
class, thai the title is assigned in the paragraphs which follow. In 
this group are included: (a) Acute pemphigus; (6) Pemphigus of 

'Bibliography: Duhring, Cutaneous Medicine, |>t. ii.. j.p. 449-468 (Phila., 
1897). Broeq, La Pratique Dermatologique, t. iii.. pp. 7^:: 838 (complete bibU 
ography). Bpiegier, Mraeek'a Eandbueh, Bd. ii.. p. l (bibliography). Grouven, 

Archly, 1901, lv., pp. 85, 247, 419 (3 plates rind bibliography). KrzyztalowiCE, 
Monatshefte, 1903, xxxvi., p. 165. Unna, Archiv, 1903, lxvi., p. 248 (abstract). 



PEMPHIGUS. 391 

the newborn; (c) Chronic pemphigus; (d) Pemphigus foliaceus; 
(e) Pemphigus of young girls; (/) Pemphigus vegetans, of Neu- 
mann. 

It will appear later that at least two of the symptom-groups 
named above will eventually be included in a different category. 

It should be understood further that these are simply clinical dis- 
tinctions of value for the time being. There are doubtless other 
forms of pemphigus ; and there are unquestionably morbid conditions 
here described which may be classed later more appropriately with 
other affections. 

Etiology. — The causes of pemphigus are obscure; yet the connec- 
tion of many varieties of the disease with changes in the trophic 
nerves and nervous centres is established by sufficient proofs. In the 
case of a young woman under our charge who succumbed to pemphi- 
gus vegetans, the remote cause of the disorder was the nervous shock 
consequent upon rape. It is well known also that traumatisms and 
lesions of the cord have been followed by bullous efflorescence upon 
the body-surface. At the same time (as Kaposi has well shown), on 
the one hand, blebs from these demonstrable causes never resemble 
the portraits distinguishable in the varieties of pemphigus; and, on 
the other hand, there is no uniformity among lesions, either as to 
anatomical site or other features, in the spinal changes to be recog- 
nized in pemphigus with a fatal issue. Further, of nine autopsies 
of bodies dead of pemphigus examined by Kaposi and Weiss, in only 
one were changes found in the cord (diffuse sclerosis). Zahn 1 has 
observed eleven cases where a pemphigoid rash followed progressive 



The view that these dermatoses are instances of infective trouble 
(auto-intoxication) is, therefore, gaining ground, and it is quite prob- 
able that future investigation will demonstrate that both the cutaneous 
and the nerve lesions are the results of a toxic agency operating with 
morbid results upon each. 

Pemphigus is reported as of more frequent occurrence in males, 
but there is doubt as to the fact. The disease is certainly more com- 
mon in infancy and childhood, because the powers of resistance at a 
tender age are inferior to those of a maturer epoch. Pemphigus 
often is observed in debilitated patients who are suffering from ( f ner- 
vous prostration," "mental worry and exhaustion," "neurasthenia," 
" general debility," visceral disorders, and impairment of nutrition. 2 
In vigorous, rosy-cheeked, strong-limbed adults the disease is rare. It 
is not inherited. The states in which there is marked impairment of 
bodily vigor are particularly favorable to the development of the 
disease. It occurs in hysteria and other neurotic affections, but the 
etiological relations which these bear to the malady are undetermined. 
We have observed one case of the disease in an adult in whom pem- 
phigus of typical appearance occurred after mental depression, which 

1 Allg. Zeit. f . Psych., 1907, Heft 4. 

'Vollmer, E., Zeitschrift, 1901, viii., p. 138; White, C. J., Boston Med. and 
Surg. Jour., 1903, cxlix., p. 297. 



RYPBB&MIA8 AND INFLAMMATIONS. 

greatly increased by the appearance of the exanthem as to 
Lead to suicide. 

In some cases, notably in pemphigus foliaceus, it is known that 
chills and fever have preceded the outbreak. A few cases of pem- 
phigus vegetans have followed mild trauma-whitlow of the digits con- 
Bequenl upon wounding the tissue with splinters. Acute pemphigus 
has followed sepsis, vaccination, rheumatic and other fevers, diph- 
theria, the exanthemata, and even long confinement in ill-ventilated 
apartments. 

There is n 1 reason to believe thai in seine of its forms the 

i- contagious. The bullous lesions, however, seen in syph- 
ilid lepra, and other similar disorders should not be included here. 

The contents of the bullae of acute pemphigus were found by Gib- 
ier, in L882, to contain bacteria. IIi< observations were confirmed 
by Vidal and Roeser. Demme 1 found cocci both in the con- 
tents of the bullae and in the blood. Whiphouse 2 found diplococci re- 
sembling those described by Demme; and by means of culture and in- 
oculation-experiments has furnished strong presumptive evidence in 
favor "!' tlie bacteria] origin of the disease. Krzysztalowicz 8 has 
recognized a streptogenous source in several unclassified forms of 
bullous dermatitis. IVrnet and Bullock* have recorded a number of 
fatal cases which occurred in butchers, the origin of which was traced 
to a local wound-infect ion. Other observers have searched in vain 
tor ;i specific micro-organism of pemphigus either in the bullae or in 

the hi I. 

Pathology. — Anatomical changes in the spinal cord have been 
recognized in pemphigus, as explained above, hut in many cases care- 
ful search has failed to discover such changes. Dejerine and Leloir 
found in a case of pemphigus changes in the peripheral nerves due to 
degeneration. 

Both in the bullae and in the blood there may he a marked in- 
crease (even to is |ter cent, i in the number of the eosinophilous cells, 
though the reverse may he true. In this respect pemphigus corre- 
sponds closely to dermatitis herpetiformis. The increase of the eosin- 
ophiloue cells in both affections has been assigned to the effect of 
;m irritant upon the nerve-centres. Coe B calls attention to the fact 
that in some rapidly fatal cases of pemphigus the eosinophilic leuko- 
cytes may he reduced to six per cent, of the normal number; and 
cites the case reported by liii--. in which the disease was fatal in a 
fortnighl and there was entire absence of eosinophilia. Grinew 6 
found the number of red blood corpuscles diminished; the white cor- 
puscles slightly increased; and the volume of the erythrocytes 

1 Vierteljahr., Ism;, p. 636. 

* London Lancet, May ii. ls;i<;. 
:i Loc .it. 

* I'.. .1. D., L896, \iii.. pp. L57 and 205 (with references to literature on acute 
pemphigus). 

Aiiirr. Med., t!»<>L\ -'"iir 28, |>. 1093. 
•BusBuche Zeitachr. f. Il.-mt and vener. Krankheiten, L904, Bd. \iii. 



PEMPHIGUS. 393 

smaller, the blood as a result being more fluid. The hemoglobin 
content is markedly reduced ; the number of lymphocytes is dimin- 
ished; the number of mononuclears and polynuclears slightly in- 
creased. The neutrophile leukocytes are increased; the eosinophiles 
diminished ; the basophiles absent. 

Most of the bullae are situated superficially between the rete and 
the horny layer or in the upper part of the rete. ISTikolsky 1 believes 
a feeble coherence between the stratum corneum and the stratum luci- 
dum to be characteristic of the disease though the value of the 
Nikolsky symptom is denied by Trauffi. 2 Dubreuilh calls attention to 
the intimate relationship between pemphigus and epidermolysis es- 
tablished by the facility of separation of the individual layers of the 
epidermis, congenitally bequeathed in the one case and acquired in 
the other. The bullae may be the result of an inflammation in the 
corium, but more probably are due to a mechanical separation of the 
rete-cells by a sudden effusion of fluid from the vessels of the derma, 
the papillae becoming at the same time markedly cedematous. In the 
final stage of chronic pemphigus, extensive and deep infiltration of 
the vessels, and peri-vascular infiltration involve the cutis. The 
lymph-vessels and lymph-spaces are dilated chiefly at the margin be- 
tween the cutis proper and the papillary body. The ridge-net is hy- 
pertrophic, containing mitoses, a normal granular layer, and a horny 
layer varying in thickness. In pemphigus foliaceus the ridge-net is 
flattened, and the suprapapillary layer is reduced to a minimum, so 
that the altered corneous layer stretches almost immediately above 
the heads of the cedematous papillae. In general the cedematous 
epithelium is softened, and the prickle-borders and the interspinous 
spaces disappear. The epithelial cells of the coil-glands are swollen; 
those of the ducts to a less extent. In time the epithelial linings 
of the hair-follicles disappear with the hairs. The entire process 
points to a persistent vascular paralysis, with dilatation especially 
of the subpapillary lymph-vessels, and an cedematous swelling of the 
constituents of the skin, denser in the connective tissue, and accom- 
panied by softening of the epithelium. The hairs and sebaceous 
glands play a purely passive part. Clegg and Wherry 3 found in five 
cases of pemphigus neonatorum and one case of pemphigus conta- 
giosa of the tropics micrococci similar to those described by Alm- 
quist. 4 The authors advise that the name pemphigus contagiosus 
be employed whether the disease affect children or adults and that the 
organism be described as micrococcus pemphigi contagiosi. 

In pemphigus vegetans, cultures from the fluid contained in the 
blebs are either negative or indicate the presence of staphylococcus 
aureus. Hamburger and Rubel found micrococcus lanceolatus in 
the lungs and a pseudo-diphtheria-bacillus in the blood of their patient. 
In most autopsies of victims of the disease no visceral changes have 

i Nikolsky, Wratscheb. Gaz., 1902 (abstr. in Archiv, 1903, bav., p. 452). 

2 Giorn. Ital. d. Malat. Ven. e. d. Pal., 1905, Heft 5. 

3 Journ. Infect. Dis., 1906, iii., p. 165. 

4 Ztschr. f . Hyg., 1891, x., p. 253. 



394 BYPBRJIUIA8 AND INFLAMMATIONS. 

been found; but in the case reported by Mr. Hutchinson a lympho- 
sarcomatous tumor was recognized near the spine, and in it were 
embedded the pancreas and la.. Hamburger and Rubel 

recognized a Bimilai tumor originating in the thymus and lying in 
the anterior mediastinum. 

Weidenfeld, 1 in an exhaustive study of the histology of the dis- 
ease, calls attention to the enormous dilatation of the blood- and lymph- 
vessels always present, together with the cellular infiltration of their 
walls, the oedema of the papillary layer of the cutis, the changes in 
the elastic tissue fibres, which may be wanting in cases, and the cedem- 
atous condition of the Pete, He believes the dilatation of the ves- 
sels to be idiopathic and unconnected with epithelial changes. Fabry 2 
points out that in pemphigus foliaceus, the importanl morbid symp- 
tom is not bleb-formation, but the granulomatous condition of the 
cutis with secondary parakeratosis and secondary changes in the 
vascular and secreting systems of the skin. Pellagatti 3 in describ- 
ing lesions recognized post mortem, in a case of pemphigus, found 
75 per cent, of large mononuclear cells in the bone-marrow of the 
femur with an homogeneous protoplasm and a nucleus poor in chro- 
matin; there were 12 per cent, of eosinophilous cells; 7 per cent, of 
small lymphocytes and the remaining 6 per cent, mononuclear. The 
changes were conspicuous at the periphery of the medulla and gradu- 
ally diminished toward the centre. 

Diagnosis. — From what has preceded, it will be inferred that 
pemphigus is a name given to a disease, and not merely to bullous 
lesions upon the surface of the skin. It is of importance to remem- 
ber this fact, as several authors have used the term in a purely de- 
Bcriptive sense, the truth being that bullae are manifestations of several 
disorders, including syphilis, lepra, herpes iris, and erythema multi- 
forme. 

At the outset the bleb- of pemphigus can scarcely be differenl Lated 
from those of other diseases. It is necessary for the recognition of 
the malady that consideration be bad of all the cutaneous and other 
phenomena present. 

In the bullae of lepra there is usually coexisting cutaneous anaes- 
thesia, and the involution of the bleb is followed by a strikingly 
characteristic atrophic patch, usually pigmented and insensitive. In 
pemphigus foliaceus the extraordinary and usually generalized des- 
quamation which ensues is sufficiently distinctive, though it. must be 
borne in mind that several varieties of pemphigus may be trans- 
formed, the one into the other, by well-nigh insensible gradations. 
Among its graver forma susceptible of such transformation may be 
mimed impetigo herpetiformis, pemphigus cachecticus, pemphigus 
diphtheriticus, and pemphigus pruriginosus. 

In herpes iris the lesions are more vesicular than bullous and 

1 \H-i,iv. L903, Ixvii., p. 409. 
•Archiv, 1904. Ixxx., p. 183. 
(Horn. itai. a. M.-il. v.'.i. e. d. Pelle. L905. Paso. 1. 



PEMPHIGUS. 395 

much more transitory ; are concentrically arranged and vary in color ; 
and are situated more frequently upon the extremities, especially the 
backs of the hands. The bullous lesions occasionally seen in urtica- 
ria and erythema multiforme are to be recognized by the other char- 
acteristic symptoms of those diseases ; in the former, more particularly, 
by their intermingling with typical wheals, and in the latter by 
the location of the eruption and its climatic or seasonal significance. 
Some of the reported contagious forms of pemphigus, epidemics of 
which have been described by Besnier, Hervieux, and other French 
authors, were possibly, as Duhring suggests, instances of impetigo 
contagiosa. This inference is sustained by the frequent allusion of 
the writers named to the " varicellaform " appearance of the lesions. 
The lesions of true pemphigus are neither contagious nor auto-inocul- 
able. 

In syphilis blebs are rare in the adult, and relatively more fre- 
quent in infants hereditarily diseased. In infants the blebs usually 
are seen at birth, often upon the palms and soles, are often pus-filled, 
and frequently are superimposed upon an exulcerated base. The co- 
existence of mucous patches of the mouth, the vulva, and the anus 
with the other characteristic lesions and signs of grave cachexia, will 
indicate usually the nature of the disease. The cutaneous symptoms 
of infants thus affected are designated improperly as pemphigus. 
Such an eruption is a bullous syphiloderm. 

In a large proportion of cases pemphigus vegetans has been mis- 
taken for syphilis, the close grouping of the lesions about the ano- 
genital region, and their striking resemblance to condylomata, taken 
in connection with the presence of erosions of the mucous membrane 
of the mouth, being the grounds for error. In pemphigus vegetans 
the vegetations are more superficial than in syphilis, are of more 
rapid evolution, and exhibit fringes of blebs at the border of any 
suspected lesion, while the genital condyloma has a smooth border 
without traces of a bullous efflorescence. ■ Further, the surface is 
"stippled" (Neumann), and never smooth as in condyloma, and the 
mouth-lesions are far more painful. 

However closely packed together may be condylomata of this 
region, they rarely spread, as does pemphigus vegetans, beyond the 
regions adjacent to the mucous outlets; while the bullae of pemphigus 
vegetans, when the disease is fairly advanced, are not only exceed- 
ingly numerous and closely packed together, but they spread also 
beyond — high toward the pubes and low over the inner faces of the 
thighs. There is commonly a history of fever, no lymphatic adenop- 
athy, and a distinct uniformity of lesions, each separate element being 
of bullous type. Dermatitis herpetiformis and some forms of pem- 
phigus are " closely related," as Duhring suggests. The grouping, 
subjective symptoms, and even the lesions of the disorders are often 
alike. It is probable that their exact relationship may be determined 
eventually. 

Some ingested medicaments are capable of producing bullous 



396 HYPEREMIAS AND INFLAMMATIONS. 

lesions, for example, potassium iodide ; such a possibility should 
always be borne in mind when establishing a differential diagnosis. 
Scabiee in infants and older children is occasionally characterized 
by ilif formal ion of blebs, in which ease the other lesions present, as 
also a history of contagion and the discovery ^<i the parasite, will point 
t<> the real nature of the disease. 

Lastly, the external application of cantharides, mezereon, the 
stronger acids, alkalies, and other chemicals may be followed by 
blebs produced either by accident or by intention with a view to 
feigning disease. The intentional production of such symptoms is 
usually effected upon the anterior faces of the lower extremities, 
regions within easy reach of the right hand. Erysipelas and derma- 
titis calorica are also affections in which blebs appear, always, how- 
ever, of minor significance as compared with the other symptoms of 
disease present. The same may be said of the bullae which form upon 
a gangrenous integument. 

Treatment. — The internal treatment of pemphigus is a matter of 
importance, as will be suggested by even a brief consideration of the 
constitutional states in which it occurs. Hutchinson 1 believed that 
" arsenic is a specific for the state of health upon which relapsing 
pemphigus depends." This remedy should be employed, if at all, 
with caution and in accordance with the rules prescribed in the sec- 
tion on Psoriasis. Kaposi declared that he had been unable to obtain 
favorable results from its employment. Iron, quinine, ergot, strych- 
nine, and the mineral acids are indicated in many cases, in conjunc- 
tion with a nutritious diet. Cod-liver oil and the malt preparations 
on the market should not be neglected. Salicin (Crocker), 15 grains 
(1.0) three times daily in water, has been useful. Not infrequently 
the treatment should be directed to the relief of the anomalous dis- 
turbances of the sexual function in women, as pemphigus has been 
found to occur in the hysterical and chl orotic states common as a re- 
sult, of functional disorder. Cassiiet, and Micheleau 2 report curative 
results in the treatment of pemphigus by exclusion of salt from the 
dietary. 

The local treatment of the lesions should consist, first, in punc- 
turing each bleb with B fine needle, in order to give exit to its con- 
tents, which should carefully be removed from the skin with the aid 
of OOtton-WOol. Then the parts are to be wholly enveloped in an 
antiseptic wet dressing, or freely dusted with a powder, such as boric 
acid, zinc Btearate, or borated talcum. When there is considerable 
pyrexia, with heat and distress in the skin, the affected surface may 
be treated as an acute eczema, with oleated lime-water, containing 
opium and carbolic or dilute hydrocyanic acid in some such propor- 
tions BS those already detailed. Weak sulphur ointments and saliey- 
lated pastes may often be used with advantage. 

The ordinary lead-and-opium wash, with or without the addition 

1 Lecture* on Clinical Surgery, London, .T. and A. Churchill, 1878, p. 49. 
Aivinv gen. de Med., 1906, Jan. 10. 



PEMPHIGUS. 397 

of zinc-oxide, may also answer a good purpose. The continuous hot 
water bath still enjoys among experts the highest favor in the treat- 
ment of the grave forms of pemphigus. Kaposi kept a patient day 
and night for eight months with his body thus immersed, to the 
great advantage of the invalid. This continuous bath is often im- 
practicable outside a large hospital; but in cases of grave pemphigus 
the continuous hot water bath has been employed in private practice 
with the happiest results. 

In pemphigus vegetans internal treatment should be directed, usu- 
ally along the line of elimination and support; locally, the contin- 
uous bath affords speediest relief. If this cannot be obtained, the 
lesions should be cleansed thoroughly and dressed with antiseptic lo- 
tions or ointments, or dusted with borated, salicylated, or camphor- 
ated powders. The numerous scalp-lesions require cutting short the 
hairs of the head in order to make applications. Alcoholic stimu- 
lants are in most cases essential. 

Prognosis. — The prognosis in mild cases of pemphigus, though 
much less grave than in the malignant forms of the disease, should 
always be formulated with caution. Unlike several of the diseases 
heretofore considered, the affection is one not frequently encountered 
in persons of fair general health. The constitutional condition of the 
patient must carefully be considered ; the disease is not only one liable 
to relapses, but also is one in which the graver may succeed the more 
benign manifestations. A flaccid summit of the bleb, sanguinolent or 
ichorous contents, an abundant efflorescence, and a rapid succession of 
new, after the involution of more ancient, lesions, are in general un- 
favorable symptoms. The same may be said of degeneration of the 
floor of the bleb after rupture and discharge of its contents. Per- 
sons of advanced years, the cachectic, the asthenic, and women 
overtaxed in childbearing, rarely are relieved when attacked by 
graver forms of the disease. Albuminuria, pneumonia, diarrhoea, 
and the inability to insure nutrition of the body when the mouth is 
sore, are all unfavorable complications of the disease. 

PEMPHIGUS ACUTUS. 

(Febris bullosa, Pemphigus febrilis.) 

In this rare form of the disorder the course of the morbid process 
is relatively rapid in the direction often of a grave termination or 
toward recovery, a few days or weeks sufficing for the cycle of mani- 
festations. We have had under observation four adults exhibiting 
classical symptoms of the disorder, one young woman dying in a week 
after the onset of the attack. The subjects, however, are usually 
children. 

There is usually a premonitory malaise with chills and fever, fol- 
lowed by the rapid efflorescence of split-pea- to small-egg-sized blebs 
symmetrically and at times very generally displayed over the body- 



398 



HYPEREMIAS AND INFLAMMATIONS. 



surface. There is about many of the lesions a distinct halo. The 
mucous membranes, more particularly the mouth, may be involved 
slightly or extensively or be -pared wholly. The eruption when 
developed is accompanied by a febrile process; the Bystemic signs of 
grave prostration arc commonly present; the eruptive phenomena 
may be developed in cycles or in single rapid explosion; and the 
contents of the blebs may be pellucid, cloudy, purulent, hemorrhagic, 
or even gangrenous. In fatal cases there are coalescence of blebs, 
a purulent and bloody character of their contents, and the denuda- 
tion of large areas of the skin whence have been removed the outer 
Layers of the epidermis. In cases about to terminate fatally there 
are also usually a precedent flaccidity of the bullous envelopes, and 
the symptoms of grave toxaemia (stupor, albuminuria, anuria, etc.). 

Fig. 68. 




Pernet 1 collated seventeen eases, the history of many of which seems 
to point to an origin from infection with septic animal poison (cases 

1 Fernet and Bulloch, B. J. D., viii., 1890, p. 157, 



PEMPHIGUS NEONATORUM. 399 

occurring after bites of animals, in butchers, etc.). In the cases 
examined, a diplococcus was recognized by Demme which is supposed 
to have been the etiological factor present. 

Bowen 1 reports a case of acute infectious pemphigus occurring in 
a butcher during an epizootic of foot and mouth disease. He reviews 
the entire literature of the subject. Kohler 2 reports an epidemic of 
acute pemphigus involving seven persons, three adults. Caie 3 de- 
scribes a fatal case occurring in a farm laborer who had been handling 
cattle. 

If it be demonstrated eventually that the disease invariably has its 
origin in the infection of a trauma with septic material of animal 
origin, the affection should be assigned to another category than pem- 
phigus. Children may thus be infected as well as adults, but in the 
former event the results are not to be confused with those recognized 
in Pemphigus neonatorum contagiosus, described below. 

PEMPHIGUS NEONATORUM. 

(Pemphigus Contagiosus Neonatorum Acutus; Pemphigus Epi- 
demicus; Pemphigus Contagiosus.) 

This is a disorder obviously contagious, occurring usually in epi- 
demic form, and affecting newborn infants. 

The first symptoms noted are punctate and larger reddish macules 
resembling a flea-bite. These enlarge and a thin pellicle forms over 
the spot, from which later vesicles develop as large as hazelnuts. 
The lesions often burst before reaching maturity, the areola mean- 
time spreading over a space with a diameter of several centimetres. 
After bursting, the areas of involvement spread with centrifugal de- 
nudation of the epidermis. The fluid furnished by the lesions is 
scanty or abundant, golden-yellow or, especially in cases that prove 
fatal, grayish-tinted. The regions affected' are the abdomen, groins, 
axillae, nates, neck, genitals, inner aspect of the thighs, the flexures 
of the elbows and knees, and, to a. certain extent, the face. As the 
disease often proves fatal, the symptoms of systemic disturbance in 
such cases are well marked, including inappetence, abdominal disten- 
tion, vomiting, oedema of the lungs, cyanosis, and dyspnoea. 

The disease occurs also in milder type, in which the lesions are 
relatively few, the areolae about the vesico-bullse fade, yellowish crusts 
represent the desiccation of the blebs, the contents of which become 
gradually scanty. 

Maguire, 4 Adamson, 5 Holt, 6 and others have made interesting 
contributions to the subject. The proof of the transmission of the 
disease to children from midwives, nurses, and attendants by the 

1 J. C. D., 1904, xxii., p. 253 (2 illustrations). 

2 Deutsch. Arehiv klin. Med., 1899, lxii., p. 5. 

3 Brit. Med. Jour., 1903, p. 308. 

4 B. J. D., 1903, xv., p. 427. 
6 Ibid., 1903, xv., p. 447. 

* N. Y. Med. Journ., 1898, Feb, 5, 



400 WYPBRMMIAB AND INFLAMMATIONS. 

medium of the bands, the clothing, etc., is incontestable. In Oster- 
mayer's case 1 the mouth of a child affected with pemphigus neo- 
natorum seems to have infected the nipple of the mother, the infant 
dying from malnutrition a> a consequence of the oral lesions. 
ICaguire shows thai in every fatal case the stump of the umbilical 
cord had been infected. The disease is without question due to 
transference of pus-cocci I Staphylococcus pyogenes aureus ?) from one 
individual to another. It is now generally admitted thai the affection 
is really an infantile form of Fox's impetigo contagiosa. Adamson, 
however, calls attention to the warning of Sabouraud, that the sta- 
phylococcus i> invariably present as the result of a secondary infec- 
tion, and that by the use of a fluid medium securing anaerobic con- 
ditions the streptococcus may be recognized. 

Hod in oer- calls attention to the close resemblance between derma- 
titis exfoliativa neonatorum and pemphigus acutus neonatorum. In 
epidemic development, it cannot be doubted that the two conditions 
designated by these names appear to be from both the clinical and 
pathological points of view identical. 

It follows from what precedes that pemphigus neonatorum also 
may properly be removed from the category of affections strictly cata- 
logued as pemphigoid. 

CHRONIC PEMPHIGUS. 
(Pemphigus Vulgaris.) 

The term Pemphigus Chronicus is applied to the more common 

clinical forms of the malady, and it has been employed gcnerically 
by many authors to include all varieties of the disease. The title 
Pemphigus Diutinus has been used also to designate that pemphigoid 
eruption in which the characteristic lesions follow each other with 
rapidity and in profusion, fresh bullae appearing each day. Fortu- 
nately, all forms of the disease are relatively rare. 

The cutaneous lesions in chronic pemphigus arc usually preceded 
by febrile symptoms; and the disturbance of the economy is declared 
in cardiac, respiratory, and gastro-intestinal derangements of func- 
tion. The fever may be continuous, remittent, or intermittent, and is 
usually aggravated just before the appearance of a fresh crop of 
blebs. 

The face, the trunk, and the extremities are chiefly involved. 
The eruption lirs! appears bilaterally, somewhat symmetrically or 
asymmetrically, in reddish macules of rather vivid hue, in the centre 
of each of which appears later a whitish elevation of the epidermis 
suggesting a wheal. Either upon these or upon unaffected points of 
the skin there subsequently form tense, well-rounded or oval vesicles 
developing into bulla varying in size from that of a pea to that of a 
hen's egg and even larger, and in number from three to six only, to 

1 Ar.-liiv, 1908, Ixvii., p. 109. 
»Archiv, l'JUG, lxxx., p. 349. 



PLATE XI 




Chronic Pemphigus. 



CHRONIC PEMPHIGUS. .401 

a hundred and more ; they are usually irregularly distributed (Pem- 
phigus Disseminatus) , but they may be clustered in groups, or very 
rarely be found the younger encircling the older lesions, so as to form 
a circinate patch (Pemphigus Circinatus) ; their contents are serous 
or bloody (Pemphigus Hcemorrhagicus) , or, later, purulent, the color 
corresj)onding with that of pus. The bulla? often coalesce, and, 
whether ruptured or not, the involution of the lesion is accomplished 
by desiccation and crusting, the crusts being usually found to contain 
blood, pus, epithelial debris, and the exudate from the base of the 
bleb. Beneath such a crust there forms a new epidermis, which is 
usually violet, purplish, or bluish red in color, and which later dis- 
plays a brownish pigmentation which may survive the disease for 
several weeks. The evolution and involution of a single lesion may 
be accomplished within a few days, but the survival of the disease in 
successive eruptions may extend through weeks or months. 

Fox 1 describes a case of pemphigus which, in the case of a woman, 
lasted for nine years and eventually presented the clinical features 
of pemphigus congenitalis (epidermolysis). 

Occasionally the affection occurs with very mild and even insignifi- 
cant phenomena (Pemphigus Benignus). There may be no fever, 
and very few blebs appear ; in some cases but a single lesion can be 
seen (Pemphigus Solitarius). In other instances the fever is in- 
tense ; the eruption abundant ; the skin cedematous, painful, pruritic, 
excoriated ; and the underlying lymphatic glands are enlarged. This 
general condition with exacerbations and remissions may persist for 
months, and the eruption may then disappear never to return, or to 
recur, as it often does, in the future. 

Clinically, many of the distinctions between the varieties of pem- 
phigus disappear. Between the benign processes just considered and 
the grave form of pemphigus foliaceus described below several inter- 
mediate gradations can be observed, and even the most benign may at 
times unexpectedly assume the most malignant phases. Pemphigus 
Malignus is a name given generally to those intermediate varieties of 
the disease, most of which are distinguished by persistent and pros- 
trating fevers ; by cachexia, especially in infants ; by the occurrence 
of diphtheritic patches upon or about the lesions, with infiltration 
of the derma and slough of its superficial layers ; or by extensive 
crusting, and even subsequent ulceration. 

In all varieties of pemphigus the lesions may be exhibited upon 
the mucous membrane of the accessible outlets of the body. 

Chronic pemphigus exhibits the greatest variation both as to its 
symptoms and as to the period of their efflorescence. There may be a 
week or a month of immunity, followed by benign relapses or by ma- 
lignant and rapid recurrences. Chills, fever, gastro-intestinal dis- 
turbances, and even profound depression may precede one or each of 
a series of eruptive phenomena. The bullae may form upon an unal- 
tered or a deeply hypersemic skin, in all sizes from that of a pea to that 

1 B. J. V., 1907, xix., p. 318. 
26 



402 HYPEREMIAS AND INFLAMMATIONS. 

of an orange, invading the skin and mucous Burfaces including the 
vagina, tin- lesions at the- base exhibiting the several features described 
above. The eruption is rarely generalized, and throughout the 
course of the disease no1 more than half a dozen lesions may at any 
momenl be visible upon the surface of the skin. Their contents may 
be removed by evaporation, absorption, or rupture, leaving a crust the 
color of which is Largely determined by the contents of the bleb. 

The areola, which may or may not l>c present in the several forms 
hen- described, is commonly narrow, and is fully developed only when 
the bleb is mature. The separate lesions may persist for days, or 
may rapture at an earlier period, leaving behind a superficial excoria- 
tion which after healing exhibits pigment. 

The intercurrent disorders in the several forms of the disease 
designated may be numerous, death occurring from septicaemia, ex- 
haustion (especially when a deep slough results, as in pemphigus 
gangraenosus), and lymphangitis, the neighboring vessels and glands 
exhibiting evidence of the toxic effects produced by the cocci present. 
In some cases the general symptoms are absent or are insignificant, 
and the subjective sensations are limited to a slight feeling of burning 
or of tension. In other cases the blebs project from the affected sur- 
face and are well distended ; in still others they are flaccid, the roof 
partially collapsing upon the serous, purulent, or bloody contents. 
The crusts which form are rarely bulky: they are more commonly 
dark colored and thin. 

Pemphigus Pruriginosus is a name applied to that grave form of 
the disease in which the lesions give rise to an intense pruritus. As a 
result of the scratching induced by the pruritus they are torn, exco- 
riated, and commingled with the crusts and exudations of an arti- 
ficially engendered dermatitis. If the itching be severe, the vesico- 
bullse may be so torn as to be difficult of recognition. Several of the 
malignant and intermediate forms may terminate fatally. 



PEMPHIGUS FOLIACEUS. 

(Bullous Dermatitis.) 

Pemphigus foliaceus is a rare variety which may originate in one 
of the common dermatoses or in a grave form of pemphigus chronicus, 
Or may. at the onset, present characteristic features. Hallopeau and 
Founder have reported cases which began as a dermatitis herpeti- 
formis. The lesions are flaccid bullae, which are developed without a 
perceptible preexisting exanthem, and which speedily rupture and 
discharge their ill-conditioned contents, leaving beneath an excoriated, 
reddish or purplish, and at times inflammatory surface. Often the 
blebs are denned so poorly that the epidermis seems scarcely raised 
from the tissue beneath, the condition resembling that of the skin to 
which a blister has been applied, with the result of imperfect vesica- 
tion. The contents, at first pellucid or lactescent, become later puru- 



PEMPHIGUS FOLIACEUS. 403 

lent or sanguinolent. When rupture of the blebs occurs, there form 
yellowish-brown crusts which acquire a feeble attachment to the 
centre of the floor of the original chamber, while the edges remain 
free; these edges, visible over the affected surface, in polycyclical or 
irregular outlines, incompletely hiding the raw and sodden epidermis, 
present a characteristic picture. 

The disease spreads gradually until it becomes symmetrical and 
universal, a peculiarity which marks it as unique among the pemphi- 
goid eruptions, and which, in a striking degree, distinguishes it from 
pemphigus vegetans and from pemphigus acutus. As the disease 
advances the patient lies in a pitiably helpless condition, the remain- 
ing epidermis being completely undermined by the serum exuded, in 
places exposing large denuded areas of skin in a condition of inflam- 
mation of a low grade. Even, however, when the disease is fully gen- 
eralized the appetite and bowel-function are at times unimpaired. 
In its later stages, after it has become generalized, the pemphigoid 
origin of the disease is not always easy of demonstration. In these in- 
stances large masses of greasy scales are exfoliated from the surface, 
the moisture proceeding from which is scarcely sufficient to attract at- 
tention. The odor from the body becomes offensive ; fissures form in 
the infiltrated skin ; the f acies of the patient may become as repulsive 
as in some forms of lupus or variola; the swollen hands with dis- 
torted nails and contractured fingers resemble claws. 

The disease affects the mouth and throat, denuding the mucous 
surfaces of the epithelium. The scalp becomes affected, as also the 
covered portion of the body. The hairs remain attached for a long 
time, but eventually they are completely swept away. Over the face, 
at first merely reddened and scaling, occur retractive processes which 
at times produce ectropion and consequent conjunctivitis. Over the 
body, especially at points pressed upon when reclining, profound 
ulcerations may destroy the deep skin. The palms and soles are in- 
filtrated and fissured rather than the seat of much exudation. The 
nails are commonly furrowed and distorted; occasionally they are 
shed. The subjective sensations are those of burning, smarting, and 
soreness, rather than of itching. If the patient be kept in the con- 
tinuous water bath, though the disease be not thereby ended, the com- 
fort of the sufferer is admirably secured. 

There may be no fever, or there may be a rise of body-tempera- 
ture with recurrence of lesions which, in a late stage of the disease, 
appear in the sites of those which have been very imperfectly followed 
by attempts at repair, a thin and glazed epidermis forming, in cases 
of chronic type, in the sites of former bullae. In other cases the tem- 
perature remains above normal for weeks at a time, especially in 
advanced stages of the disease. The malady may complete its course 
in a few months or may persist for years and though not necessarily, 
yet is unquestionably fatal in the majority of cases. Death usually 
results from exhaustion; occasionally an intercurrent pneumonia or 
diarrhoea concludes the history. Pemphigus foliaceus commonly at- 



404 HYPBBAJMIA8 AND INFLAMMATIONS. 

Eidults, bul Brand 1 reports the occurrence of the disease in a 
newborn child. 

The Inherited Form of Pemphigus U described by Goldscheider, 
and others, and is most often noticed in summer, spring, or 
autumn, rarely in winter. The malady is considered under the title 
of epidermolysis bullosa hereditaria. 

Pemphigus of Young Girls {Pemphigus Virginum, Pemphigus 
Chlorotieu8). — This disorder, described by Hardy 2 and Tommasoli,* 
i- characterized by the appearance upon tie skin, of oval or rounded 
spots of a reddish or rosy hue; upon these spots develop later 
vesico-bullse "t" different sizes which speedily burst and are followed 
by tin- formation of thin crusts. It has been suspected that some of 
these are instances of feigned eruption (7. v.). The subjects of the 
disease an- between the fourteenth and the twentieth year of life, 
unmarried, and usually menstruating irregularly. Others have de- 
scribed a "pemphigus hystericus," to be recognized in hysterical 
persons of the same class, alternating or corresponding with hyster- 
ical attacks, the eruption not uniformly disposed over the surface, 
and being transitory in duration, disappearing with relative rapidity 
and h-aving no cicatricial traces of it< existence. Onna dismisses 
this affection from the category of trite pemphigus. 

PEMPHIGUS VEGETANS.' 

1 Ki;ytiik.\ia Buixosum Vegetans, Heepes Vegetans, Condyxq- 
matosis. Pemphigoides Maligna.) 

Xiuniann" in 1 SSTJ was tirst to describe and furnish illustrations 
in color of a disease to which he gave this name, and which has since 
been studied by a number of observers. Crocker, of London, pub- 
lished an excellent monograph giving tabulated results in some eigh- 
teen cases ; and I published a report of the first case recorded as such 
in the United States. 

The onset of the disease may be marked by languor, malaise, 
febrile symptoms of moderate severity, and ill-defined symptoms of 

1 Brit. Med. Jour., June 7, 1902. 

*Trait£ prat. e1 descript. des Mai. <1<- la I Van. Paris, 1886, p. 268. 
Jour. MaL eutan., L895, \i.. p. 1 19. 

* Literature of [mportauce: Neumann, Archiv, 1886, xiii., p. 157; J. C. D., 1889, 
].. 387. Kohn (Kaposi), Archiv, 1869, vol. 1. Radcliffe-Crocker, Dis. of Skin, 
and Brit. Med. Jour., No. 16, 1889, p. 590; Med. Chir. Trans.. 1889, \<>l. 
Jxii.. reprint, London, 1890. Jamieson and Welsh, B. J. D., 1902, xi\.. p. 287 
(report of ease with autopsy and histology). Hamburger and Rubel, Johns Hop- 
kins Bull., L903, xiw. p. 63 (with report of case, autopsy, histology, and review 
of eases to date). Ormsby and Bassoe, J. C. D., 1905, xxiii.. p. 294 (acute malig- 
nant pemphigus with autopsy). Eischkin, Chicago Med. Rec., 1901 (report of 
infantile case resembling symptoms in adult). Winfield, J. C. D., 1907, xxv., p. 
17 ami p. 71 (review of all eases reported to date, report of author's case, 3 
illustrations, and bib.). Bavogli, Trans. Amer. Derm. Assn.. 1905, Dec. 28-30th. 
Zumbusch, Archiv, 1905, lxxiii.. 121. Brocq, L., La Pratique Dermatologique, t. 
iii.. |>. 7s7; Constantine, E., Annales tie Derm, et de Syph., 1907, p. 641. Ferrand, 
M.. ibid., L907, p. 254. 

■'• Viertrljalir. iSSfi, Hand xiii. 



PEMPHIGUS VEGETANS. 405 

impaired health, after which the morbid phenomena may be declared 
in the mouth or the skin. In the former region white patches, which 
are ill-developed blebs that may exhale an unpleasant odor, are 
visible upon the mucous surface. The detached membrane forming 
each spot, finally is loosened and leaves behind equal-sized excoriated 
patches, which produce extreme soreness of the mouth, and which 
as some heal are succeeded by others. In severe cases they render 
mastication and deglutition exquisitely painful; and in patients in 
whom this becomes a prominent feature of the case the nutrition of 
the body as a consequence is impaired seriously. 

The skin-lesions may precede or may follow those in the mouth. 
They commonly are seen first in women about the vulva, spreading 
over the ano-genital region and umbilicus as closely set bullae covered 
with a mucoid whitish secretion, the features thus strongly resem- 
bling the appearance of condylomata of the same region. In con- 
nection with the mouth-lesions, the suggestion that syphilis is present 
is very striking, and has led to this error of diagnosis in a large 
number of instances reported by those not expert in diagnosis. In 
other cases the scalp, hands, feet, axillae, and other parts are in- 
volved primarily. The bullous or vesico-bullous efflorescences, which 
at first resemble those of other forms of pemphigus, speedily exhibit 
at the site of their production, excavations, ulcerations, or more com- 
monly vegetating masses, the change from the bleb to a fungoid 
papillomatous growth being scarcely appreciable. The lesions may 
coalesce and tend to become grouped about the axillae, the circle at the 
root of the neck, the bend of the elbows, the hands, the feet, and 
the scalp, but they have no tendency to become universal, even when 
extensive. The nails may become affected as a result of the forma- 
tion of blebs in the matrix. A singular change in the skin, where 
typical, well-formed bullae have developed and healed, is a deep pig- 
mentation in puncta resembling comedones, with pin-point-sized 
verrucoid elevations of the surface. In some regions the sequence 
of the closely packed blebs, followed by vegetating masses, resembles 
that seen in pemphigus foliaceus, in which, especially over the back 
after long decubitus, there form large, granulating erosions, exquis- 
itely painful, and conducive to a rapidly fatal issue. Indelible scar- 
ring may result. In the cases reported by Zumbusch, nut-sized and 
larger tumors developed from the papillary excrescences. The disease 
progresses in unmistakable accessions of aggravation and improve- 
ment, lasting for months and occasionally for years. It is in the 
large majority of cases eventually fatal. Variations occur, chiefly in 
the degree of febrile temperature, probably always reactive; in the 
severity of the buccal lesions ; and in the extent of the eruption. The 
duration may be from a few weeks to two years. 

The disease occurs more often in women than in men, usually 
between the thirty-fifth and fortieth years of life, as a rule first at- 
tacking the throat, mouth, and nose. 



406 HYPEKJEMIAS AND INFLAMMATIONS. 

A survey of all reported eases emphasizes the view taken by 
Duluvuilh. Tommasoli, and Winfield, that the cases described by 
authors represent two rather widely different types. In the true 
pemphigus vegetans of Neumann, which is probably invariably fatal, 
lesions of grave significance develop beneath the first formed blebs; 
a second group includes the cases in which a few recoveries have 
been reported, when- the bullae of chronic pemphigus have been com- 
plicated by vegetations springing from the seat of the bullous lesions. 
True pemphigus vegetans, though without doubt related to malig- 
nant pemphigus, is a BpeciaJ disorder of infectious character, running 
a definite course, the distinctive factor in which is as yet undeter- 
mined, the changes wrought being obviously secondary in character 
and importance. 

Fox 1 reports the case of a married woman, .".7 years old, affected 
with pemphigus vegetans. "Spots" about the neck were followed 
by penny-sized blebs in the axillary region, also here and there over the 
thorax, the neck, and the limbs. The lesions became crusted, oc- 
curring in crops and after rupture, warty growths developed spring- 
ing from the base of the bleb and spreading centrifugally. The 
patient recovered under the use of arsenic. 

Pemphigus of Mucous Surfaces.- — In almost all grave forms of 
pemphigus the mucous surfaces are involved in various degrees, in- 
cluding the lining membrane of the mouth, the vulva, the anus, the 
eye, etc. Tamerl 3 recognized the presence of blebs in the oesophagus 
by cesophagoscopy. 

In these regions the lesions may be few or numerous, the bullae 
rounded, translucent, when unbroken slightly elevated above the 
general level, but often first subjected to examination after rupture. 
Mandelbaum 4 calls attention to bleb-formation in the mouth (tongue, 
pharynx), and larynx which may precede the development of similar 
lesions in the skin. In this event one sees merely the reddened floor 
of the lesion from which the limpid or dark-reddish contents of the 
bleb have escaped or are escaping. Commonly there is a vivid areola 
al-oiit the macule. After the lapse of time the floor resembles 
merely a diphtheroid patch or a spol which has been pencilled by 
silver nitrate. The lesions of the mucous membranes as in cutan- 
eous manifestations of pemphigus may be either acute or chronic; 
as a rule they suggest an element of gravity in the cases in which 
they develop. Adhesions occur bul rarely at the points where the 
membrane has been laid bare. 

1 I'.. L908, xxvi. p. 181. 

*Cf. Charles, Rev. hebdomad, <lo Laryn., d'Otolog. ct do Rhinol., 1902. xxiii., 
p. 837. Also Cocks, J. A. M. A.. L906, Nov. 24, p. L736 (report of fatal ease ox 
pemphigus with lesions limited to the mucous membranes). Charles, Row Ital. 
<1. tnal. de Laryng. cited in Axehiv, 1901, l.wii.. p. 135 (throe casos, some of acute 
and some of chronic com 

•Wien. klin. Wochenschr., 1904, No. 29. 

1 BerL klin. Wochenschr., 1892, No. 49. 



POMPHOLYX. 407 

Pemphigus in Children. — The acute form when affecting chil- 
dren is characterized by the sudden evolution of semi-transparent bullae 
of the skin and the mucous membranes, the contents of the lesions be- 
coming gradually opaque. There is usually a narrow red halo about 
each. The syndromes are fever, chills, and malaise, the latter increas- 
ing as the eruption spreads. Recovery or fatal termination usually 
occurs within a few weeks. 

The chronic, or better the recurrent, form displays lesions at in- 
tervals of a few clays and the surface of the skin exhibits in succes- 
sive crops well formed blebs. There may be, as in the acute form, 
a febrile movement, though usually this last is absent. There may 
be a fatal result. 

After a survey of the pathological findings by Kreibich, Kro- 
mayer, Luithlen, Buzzi, Joseph, Jarisch and others, even admitting 
that diplococci, staphylococci, and streptococci have been recognized 
in sections of tissue, the fact remains that the negative findings are 
almost equally numerous and the contents of the pemphigus blebs are 
often sterile; the neuropathic origin of the disease is scarcely to be 
disputed. 

POMPHOLYX. 

(Gr., iro/n<p6?ivS; , a bubble.) 
(ClIEIRO-POMPHOLYX, DySIDKOSIS. Fr., DySIDKOSE.) 

Pompholyx is a form of pemphigus affecting the skin of the hands 
and feet, occasionally also contiguous parts, where variously sized 
vesicular and vesico-bullous lesions develop. 

This disorder has been the theme of no little discussion. It was 
described first by Tilbury Fox in 1875, Hutchinson 1 reporting on the 
same case. 

Symptoms. — The disease affects simultaneously and, as a rule, 
symmetrically the hands and the feet ; if either organs are spared, it 
is commonly the feet. One side may be involved more extensively 
than the other. The eruption is preceded or is accompanied by a 
burning or a tingling pain, rarely with severe itching, and is char- 
acterized by the appearance on the dorsum, or the sides of the fingers, 
or over the palms and soles, or over the whole hand or foot, of deeply 
set, single or numerous, grouped or confluent pin-head- to bean-sized 
vesicles, or of vesico-bulhe. According to Fox, in the earliest stages 

1 Literature: Tilbury Fox, Amer. Jour, of Derm., 1873, p. 476; also Brit. Med. 
Jour., 1873, Sept. 27. Hutchinson, J., 111. Clin. Surgery, 1876; London, Fase. iii., 
PI. x. Eobinson, Archiv, 1877, iii., p. 4; also Morrow, Syst. Derm., vol. iii., 
p. 182 (Art. Pompholyx, by Eobinson). Crocker, Trans. Path. Soc. of London, 
1878, x., xix. Unna, Histo-pathology, p. 176. Leviseur, Contribution to the Clini- 
cal Aspect and Treatment of Pompholyx (Dysidrosis, Cheiropompholyx) , 14 cases, 
J. C. D., 1905, xxiii., pp. 432-439. Nestorowsky, Die anatomischen Verander- 
ungen der Haut bei Dysidrosis, Zeitschr., xiii., pp. 183, 357, 421; Annales, 1906, 
s. iv., vii., p. 978. For further bibliography, see Santi, Monatshefte, 1892, xv., 
p. 93. 



HTPBBJBMIAS AND INFLAMMATIONS. 

of the vesicles annular collections of fluid may he seen about the 
sweat-pores. The appearance of well-developed lesions is compared 
with That of boiled aago-grains imbedded within the skin. When 
the bulls attain extreme development the distended lesions, as large 
as pigeon's eggs, project from the -kin. these le.-ions hein<: irregularly 
outlined and containing a neutral or an alkaline fluid, translucent 
<>r turbid, and seated on an oedematous, often exquisitely painful 

Pig. 69. 




DysldrMia I Howard F"ox). 

and sensitive skin. The bulla* are said nol to rupture spontaneously, 
but to undergo absorption in a fortnighl or more, with exfoliation of 
the loosened epidermis; but there are well-marked exceptions to the 
rule. Beneath the purposely ruptured bullae is a new-formed and 
reddened Or exfoliated and sodden (which under favorable circum- 
stances becomes later a sound) epidermis. There may be coincident 
malaise, thermal changes, marked mental despondency, or hebetude. 
Hyperidrosis may be a prominent feature in the case of affected pa- 
tients before and during the occurrence of the disease. There may 
be recurrent attacks in consecutive seasons, and also recrudescence of 
the disease in the affected. Mild type- of the disease occur which it 
i- difficult to distinguish from pemphigus benignus. In Leviseur's 
observations, the nails are sometimes died. 

Etiology.- The disease is somewhat rare, occurs rather more often 

in women than in men, though both sexes are attacked. The ages 
extend from childhood to middle life; one well-marked case occurred 
in a man of sixty. The sutferers, with but few exceptions, are in 

I r health, are broken down from nervous oversl rain, and are neuras- 
thenic rather than cachectic. 

The disorder is in certain subjects due to strictly inherited ten- 
dencies. We have had under observation typical cases in the person 

of a mother and tWO children, one of the latter a girl, all of whom 



POMPHOLYX. 409 

had suffered since birth from successive crops of vesico-bullous lesions 
with hyperidrosis of the hands and feet. The heart of each was in an 
irritable state, the pulse rate of the mother having been repeatedly 
registered at 122 to the minute. All three patients complained of 
gastric crises. 

In France a number of disorders accompanied by coldness and 
sweating of the hands and feet, and characterized by lesions limited 
to these organs, are cited as instances of dysidrosis. Thus, a passive 
erythema and areas of congestion of the skin of the organs named, 
displaying non-bullous lesions, are commonly set down in Paris as 
illustrations of dysidrosis. It is usual in America to limit the titles 
dysidrosis and pompholyx to the affection here described with marked 
preponderance of vesico-bullous lesions as hand and foot symptoms. 

In all cases the heart should be examined and the condition of the 
circulation carefully determined. Organic and functional cardiac 
disease is responsible for many cases. 

Pathology. — The differences among observers respecting the char- 
acter of the disease depend upon whether the view is taken with Fox, 
Crocker, and others, that the vesicles lie directly connected with or in 
the line of the sweat-duct; or whether, with Hutchinson, Robinson, 
and others, no connection with the coil-glands is recognized, the vesi- 
cles lying in the superior portions of the rete over the papillae, and not 
over the rete-pegs which pass below to meet the ducts of the coil- 
glands. Crocker, however, found lesions in both situations. Unna 
believes that a micro-organism resembling the tubercle-bacillus is 
responsible for the disease. 

Nestorowsky summarizes the views of the French school on the 
subject of dysidrosis, asserting as the result of his anatomical re- 
searches, that the process originates in augmentation of the secretion 
of the sweat glands with dilatation of the excretory canal but that 
dysidrosis occurs in persons whose hands never sweat, and also that 
in many cases of hyperidrosis there are no symptoms of dysidrosis. 
Briefly, the original cause is to be sought in disorders of the nervous 
centers, but a predisposing factor is the sweating in a hand or foot 
of weakened resistance. When the cause operates efficiently, the 
horny layer of the epidermis becomes swollen, the sudoriparous canals 
are blocked with horny substance, and cystic dilatations of the sweat- 
channels result, some of which rupture and release the effused fluid. 
The result is swelling, vacuolation, granulation, and even necrosis of 
the cells. Under the influence of the pressure produced by the 
swollen cysts, the excretory conduits may form vesicular loops in the 
upper, middle, and, more rarely, the lower portions of the rete ; vesi- 
cles also form in the horny layer above the stratum granulosum, 
partly from pressure and in part from imbibition of the fluid effused. 
The blebs are formed by confluence of smaller lesions. 

By many writers the disorder is no longer regarded as a distinct 
disease, but is properly classed with other forms of pemphigus. 

Diagnosis.- — Pompholyx is to be differentiated from eczema. The 



410 HYPEREMIAS AND INFLAMMATIONS. 

tendency of the vesicles to persist, and after rupture to fail to furnish 
a serous exudate, is strikingly differenl from the course of eczema. 
Again, there is seldom, if ever, in well-marked pompholyx a tendency 
to change in type from a serous to a pustular exudation. Lastly. 
eczema of the palms and the soles is alraosl invariably of erythema- 
tous type. It differs from pemphigus in the absence of cyclical phe- 
nomena, in its special localization, and in its frequent vesicular 
origin. 

Treatment. -The internal treatmenl of these cases is of impor- 
tance Patient- require the best climatic and hygienic environment 
and mental distraction. In male patients, the use of coffee, tea, and 
alcoholic beverages is to be interdicted. In the way of medicaments, 
quinine, mix vomica, arsenic, iron, the mineral acids, ergot, cod- 
liver oil, matzool, and kumyss may be needed. The local treatment 
ia by employment of diluted black-wash, lead-water, oleated lime- 
water with zinc oxide or bismuth Bubnitrate, or Lassar paste covered 
with boric or salicylated powder; or by the application of strips of 
muslin spread with lead or with zinc salve-. Crocker recommends 
the zinc or lead oleate. In other eases solutions of silver nitrate 
(grains v to 5j [0.33-30.]) or of ichthyol 50 per cent, with water are 
efficacious. Leviseur 1 recommends xeroform powder applied on cot- 
ton and firmly bound over each individual linger. 

HYDROA VACCINIFORME. 
(Recurrent Summer Eruption. Hydboa Pukborum. Ft., Hy- 

DROA ^EsTIVALE.) 

Hydroa vacciniforme is a recurring vesicular disease, occurring 
chiefly in the summer season in the persons of young adult male 
subjects and solely on exposed parts of the cutaneous surface. 

This disease was discribed first in 1861 by Bazin and later by 
Hutchinson, Jamieson, Brooke, Crocker, 2 Bowen, 3 Graham, White, 
Brocq, 4 and others. 

Symptoms.- — The disease usually begins during the first three or 
four years of life and gradually disappears during the few years fol- 
lowing puberty. With but few exception- the cases reported have 
Keen in boys. The disease is most active in summer, the larger num- 
bers of patients remaining free from active manifestations during 
the winter months. The direct cause in most cases is exposure to the 
aun'e rays, though exceptionally warm or cold winds, or even arti- 
ficial bent, seem sufficient to cause an outbreak. 

The eruption is symmetrical and is limited to the uncovered parts 
of the body; the bridge of the nose, cheeks, and ears, and the backs 
of the bund- being the parts most affected. Bazin, however, reported 

' Loc. cit. 

i uea of the skin. L893. 
S .T. C. D., 1894, xii.. p. 81 (with review of Literature, and histology). 

4 Annates. 1MU. s. iii.. v.. p. 1003. 



HYDRO A VACCINIFORME. 411 

cases in which covered portions of the body were slightly involved. 
We have under observation a case (the subject of the accompanying 
illustration) in which a new crop of vesicles and bullae on the face is 
accompanied at times by an herpetic keratitis, the resulting scars 
interfering considerably with vision. The disease occurs in suc- 
cessive outbreaks, each of which lasts for two or three weeks. The 
intervals between recurrences in the summer may be several weeks, 
or so brief as practically to be wanting. The lesions often are 
preceded by sensations of heat or itching ; and the first to appear are 
red macules or elevations, upon which rapidly are formed vesicles 
or bullae, varying in size from that of a millet-seed to that of a large 
pea, and occurring either singly or in groups like herpes ; they may 
coalesce and may be surrounded by a halo. These vesicles may dry 
in a day or two, or they may rupture and form a crust, but many 
of the larger become depressed in the centre and resemble a vacci- 
nation-vesicle. The depressed centre is black or dark blue, and is sur- 
rounded by a ring of fluid, while about the whole is a reddened areola. 
Some of the lesions may become purulent. The dark centre is con- 
verted rapidly into a thick, black crust which is very adherent, and 
which on falling leaves a depressed, reddened scar that eventually 
becomes white and practically indistinguishable from that of variola. 
The duration of an individual lesion from its beginning to the forma- 
tion of the crust is three or four days. The time required for the 
crust to fall is variable. 

The eruption usually is preceded by some slight constitutional dis- 
turbance, and by burning or pain at the site of the lesions. Itching 
is absent, as a rule, though it was marked in Bowen's case. 

Etiology. — Exposure of sensitive skins to the sun and wind, espe- 
cially in the summer season, is the effective cause. We have observed 
patients in whom the disease was developed not merely in summer, 
but in winter when the sunlight was reflected from snow on the 
ground. Ehrmann 1 showed that light passed through blue glass was 
just as potent in causing the eruption as the sun's rays, but when the 
light was passed through red glass which absorbs the caloric rays no 
lesions resulted. He concluded that the eruption is of photo-actinic 
origin. 

Pathology. — The pathology has been studied by Bowen in two 
lesions taken from a single patient, and Mibelli. 2 In the primary 
stage Bowen found merely vesicle-formation in the middle layers of 
the rete. In a more advanced lesion he found necrosis involving the 
lower layers of the stratum corneum, the entire rete, and the corium 
nearly to the subcutaneous tissue. He concluded that the process 
begins as an inflammation in the epidermis and upper part of the 
corium, followed by vesicle-formation in the rete, and later by the ne- 
crosis described above. The necrosis is sharply circumscribed, and 
showing through the vesicles above, produces the black centre of the 

1 Archiv, 1905, Ixxvii., p. 163. 

2 Monatshefte, 1897, xxiv., p. 87. 



412 HTPBBJBMIA8 AND INFLAMMATIONS. 

advanced lesions. Bowi d further calls attention to the points of sim- 
ilarity between this disease and those of acne necrotica, <>r of acne 
varioliformis. 

Diagnosis. The diagnosis is from erythematous lupus, pemphi- 
gus, erythema bullosum, and dermatitis herpetiformis. The limita- 
tion of the lesions to the exposed parts of the body, the presence of 
vesico-blebs, and the Bcarring, in connection with the age of the 
patient, all poinl to the nature of the malady. 

Treatment. The treatment is unsatisfactory. To prevent recur- 
rence the patienl Bhould be guarded from exposure to the sun and in 
some cases from 1 1 « ■ t or cold winds. Veils and coverings which ex- 
elude the lighl may be of service. Crocker recommends treating 
the eruption by opening the vesicles and applying iodoform in pow- 
der or in solution in ether. After removing the crusts with carbolized 
oil the surfaces may be dressed with an ointment containing iodoform 
and boric acid. 

Prognosis.- --'Idie prognosis i- unsatisfactory, as until adult years 
are attained the patient is liable alter fresh exposure to recrudescence 
of the disease. 

ACRODERMATITIS PUSTULOSA HIEMALIS (Crocker). 

Under this title Crocker described a condition similar, if not 
identical with folliclis. Ee has seen three cases and described it as 

follows : 

"The lesions are excited or kept up by the cold, affect the hands 
only, especially about the knuckles and sides of the fingers, and take 
the form of indolent, indurated papulo-pustules, isolated and few in 
number at a time; but the disease as a whole persists by a succession 
of lesions throughout the winter ami early spring. 

" They begin as hard, brown, large pin-head points, but later as it' 
there was a * thorn on the flesh.' If opened early serum escapes, but 
Later pus forms around the peg and the whole is situated on an ele- 
vated inflammatory pea-sized base. The center is casl off leaving a 
scar. Some of the indurated nodules do not suppurate." 

The chief difference between this disorder and folliclis appears 
to be only one of limitation in location as the lesions are identical in 
the two disorders. Crocker 3 suggests nitroglycerine internally with 
local treatment by vasogen-iodine. 

EPIDERMOLYSIS BULLOSA HEREDITARIA. 

I Ar.WTllul.vsis I !r LLOSA. ) 

Thifl name 1 1 ; i s been given to a rare affection or condition of the 
skin in which there i< a pronounced tendency to the rapid formation 

of bullae wherever the integument may be slightly bruised <>r rubhed. 
'Crocker. 8d ed.. dp. 850 851. 



EXANTHEMATA. 413 

Cases have been reported by Goldscheider, Kobner, Valentine, 
Elliott, 1 Beatty, 2 Bowen, 3 Wende, 4 and others. 5 In the majority of 
cases reported the condition had existed from infancy or early child- 
hood, and there was a clear history of heredity. Valentine reported 
eleven cases which occurred in four generations of the same family. 

The general health of individuals thus affected may be excellent 
and the skin remain sound so long as it is subjected to no irritation, 
but in some cases very slight causes (the pressure of a shoe in walk- 
ing; the grasping of a firm substance, such as the handle of a ham- 
mer; the friction of suspenders or waistband) are sufficient to cause 
the appearance of firm, tense, blebs at the site of the irritation. 
Such bullae vary in size from that of a small pea to that of a walnut. 
They often last some days, having a firm roof -wall ; are usually more 
or less painful, especially after rupture ; and disappear without leav- 
ing either pigmentation or scar. The predisposition to the formation 
of new bulla?, however, remains indefinitely. In Bowen's case the 
bullae were often hemorrhagic in type and were followed by pigmenta- 
tion and scarring. 

Histology. — Engman 6 found an absence of elastic tissue in the 
papillary and subpapillary regions of the derma, elastic fibres were 
sparsely distributed and deformed in the deeper regions of normal 
skin. 

EXANTHEMATA. 

(Gr., e!javd//{ia, blossoming, flowering.) 

Eor a detailed consideration of the phenomena of the exanthema- 
tous fevers the reader is referred to the standard treatises on the sub- 
ject in the field of general medicine. Space is allotted here merely to 
a description of the cutaneous lesions by which they are severally 
characterized. These are unlike in each disease, yet all exhibit 
certain common characteristics. In all the eruptions are symmetri- 
cal, and in typical cases are general. In each the efflorescence is suc- 
ceeded by a desquamative or exfoliating condition of the skin. In 
each there is, within relatively fixed limits, a distinct stadium of the 
pathological process within which it is completed, and beyond which, 
however persistent may be its remote sequela?, there is no chronic 
manifestation of the disorder. Each, also, is produced solely by its 
specific contagium, derived exclusively from an animal body affected 
with the same disease, being never, so far as known, generated from 
any other source, nor merging by imperceptible degrees the one into 
another. Two of these may rarely concur, but under such circum- 
stances the one is always more pronounced in its features, which either 

1 J. C. D., 1895, xiii., p. 10; ibid., 1899, xvii., p. 539; and N. Y. Med. Jour., 
April 21, 1900. 

2 B. J. D., 1897, ix., p. 301. He gives a resume of all previously reported cases. 

3 J. C. D., 1898, xvi., p. 253. 

4 Ibid., 1902, xx., p. 537 (recent bibliography), and ibid., 1904, xxii., p. 14. 

5 For complete bibliography, see Luithlen, Mracek 's Handbueh, i., p. 737. 

6 J. C. D., 1906, xxiv., p. 55. 



414 HYPBBJBMIAS AND INFLAMMATIONS. 

:• follow those of another. No specific medication is 
known to be capable of arresting any one of them, each pursuing its 
course uninterruptedly to a favorable or a fatal termination, accord- 
ing to ili«- intensity of the poison presenl in each case and to the 
more or Less favorable or unfavorable conditions of the sufferer. Fin- 
ally, ii is probable, though not at presenl demonstrable, that specific 
microorganisms arc etiological factors in the production of each. 

RUBEOLA. 

(Measles, Morbilu. Qer., Masern, Flecken; Fr., Rougeole; 
Hal., Rosolia; Sp., Serampiox.) 

Symptoms.— After an incubation period of nine to eleven days 
prodromal symptoms of the disease appear; fever (102°— 104° F.), 
chills, rarely convulsions, incessant, hacking cough, and catarrhal in- 
flammation of the conjunctiva, nasal mucous membrane, and larynx. 
Prodromal rashes are also found in carefully observed cases; there 
may be urticarial, erythematous, or scarlatiniform lesions; Rolleston 
in 30 cases records these occurrences in 12.8 per cent, observed. 
The most important recent contribution to the literature of measles 
includes another manifestation of the period of invasion: Koplik's 
spots. They appear on the mucous membrane of the palate, uvula, 
lips, and cheeks of nearly 90 per cent, of patients, often as early as 
Beventy-two hours before the appearance of a characteristic exanthem. 
Pin-head- to split-pea-sized bluish-white glistening spots or brilliantly 
red patches with a bluish-white punctum centrally situated in each 
become visible. The value of this early sign of the disease has been 
corroborated by other observers. 1 

Period of Efflorescence. — The eruption of measles usually appears 
on the morning of the fourth day first upon the face | the forehead and 
temples), and thence extends in about thirty hours over the neck, the 
upper portion of the trunk, and the superior extremities. Between 
the fourth and sixth day of the disease it usually attains its deepest 
shades of color and its maximum of development over the entire 
surface of the body, including the palms and the soles. This maxi- 
mum attained, the eruption gradually fades; the tumid condition of 
the skin, most noticeable on the face, also subsides; the catarrhal 
symptoms and cough become less annoying; and the patient enters 
upon the period of desquamation. 

The eruption is almost invariably symmetrical, and is character- 
ized by the occurrence of a diffuse reddish, yellowish-red, mulberry- 
red, deep raspberry-red, or, in extreme cases, violaceous-tinted colora- 
tion of the skin, or of pea- to small finger-nail-sized (a millimetre to 
a centimetre in diameter), oval, round, or irregularly shaped, fairly 
well-defined macules, either uol elevated or \^vy -lightly raised above 

1 Fihtou. Acute [nfectioiiskntnk., 1 s'.t." ; Weiss. Wien. klin. Wchschrft., 1899, 
xii.. p. 688 (abstr. In B. J. D., L900, rii, p. 83); Williams, Bristol Med. and Chir. 
Jour., LI .wiii.. p. L39 (abrtr. Ln B. J. D., 1900, xii., p. 331). 



RUBEOLA. 415 

the general level of the integument; or by the occurrence of large 
pin-head-sized, discrete papules, much more rarely pin-point-sized 
vesicles, corresponding in color with the shades described above, and 
highly suggestive of the first efflorescence in variola. These lesions 
become pale under pressure, exhibiting then a yellowish tint, and 
often are set together closely, particularly over the upper segment of 
the body, in patches suggesting a crescentic outline. The term " sug- 
gesting " is used here purposely, as it is difficult, by selecting a single 
patch, to determine by the eye alone the existence of such a configu- 
ration; while an examination of the eruption as a whole may often 
very clearly convey this impression to the sight. Usually, patches 
of sound skin can be recognized even when the eruption appears to be 
confluent, complete confluence never occurring so as to form a sheet 
or mask over the entire skin-surface. Individual lesions may so 
merge as to be well-nigh indistinguishable separately; yet, on the 
whole, the eruption deserves fully the plural character of its English 
name. It is made up in all cases of innumerable elements, whose 
identity is never wholly lost. The subjective sensation awakened 
is occasionally a severe itching or burning ; frequently this is an in- 
significant matter compared with other disagreeable symptoms — the 
cough, coryza, and fever. 

The exanthem spreads from the face to the upper extremities on 
the second day, and over the lower limbs on the third day of the rash. 
Its complex expression usually coincides with decided aggravation 
of the catarrhal symptoms. 

Period of Desquamation. — The decline of the disease is accom- 
plished usually with cessation of fever and the production of delicate 
yellowish-brown pigmentations of the surface where the elements of 
the eruption have existed, involution being manifested first in the 
site of the lesions which were earliest to develop. The scaling when 
present is usually of moderate grade. Gradually and simultaneously 
the catarrhal symptoms of the respiratory passages diminish in sever- 
ity. This final stage of the disease in favorable cases usually is ter- 
minated in a fortnight from the date of invasion. 

The complications and anomalies of measles depend upon the in- 
tensity of the poison, t displayed in the most formidable symptoms 
where human beings are crowded together, as in camps and prisons ; 
upon the degree of physical vigor ; and also upon the various hygienic 
surroundings, of the victims of the disease. Thus, the period of efflor- 
escence may be unusually prolonged; the eruption may disappear 
suddenly, and as rapidly reappear; the cutaneous symptoms may 
alone be wanting ; the latter may be commingled with petechia? due to 
cutaneous extravasation of blood, which may also be accompanied by 
severe epistaxis ; and the catarrhal condition of the mucous surfaces 
affected may terminate in croupal or in diphtheritic disease, may be 
followed by capillary bronchitis, catarrhal pneumonia, and even by 
pulmonary tuberculosis. Typhoid conditions may also supervene, 
and chronic inflammatory affections of the eyes and of the Schneider- 



416 HYPEREMIAS AND INFLAMMATIONS. 

ian membrane result Measles, scarlet fever, and other exanthemata 
may concur. 1 

Etiology. The disease is infectious and contagious, being coin- 
municable from person to person, the virus being transmitted less 
readily by the medium of fomites thaD in other exanthemata, and 
usually rendered Innocuous by exposure to sunlight and air. The 
malady is inf< ctious in al] Btages even before thai of eruption ; and the 
effective agent i- present in the blood aa shown by inoculation-experi- 
luring the prodromal stage. Susceptibility, save in those pro*- 
tected by previous infection, i- general, though -.vend attacks of the 
disease arc on record, the most of 3uch, however, being open to sus- 
picion, since roseola (German measles) may follow rubeola. In the 
human family all ages and both sexes are liable To contract the- disor- 
der, and it is believed that animals arc not exempt. 

'1 he disease ha- been demonstrated to produce itself by contagion 
two to four days before the appearance of the rash, while the capabil- 
ity of transmission is usually lost between the twentieth and the 
thirtieth day after the exanthem is fully developed. 

Pathology. — The pathology of the cutaneous lesions in measles is 
that merely of acute hyperemia occasionally passing into exudation, 
limited for the mosi part to the vascular papilla? of the curium and 

the perifollicular plexuses of bl l-vessels. There is oedema of the 

fatty tissue surrounding the coil-glands, in the sheaths of the larger 
vessels, the cutaneous muscles, and the hair-follicles. The coils, folli- 
cles, and muscles seem to swim free in widely dilated spaces. There 
is no cellular exudation and no mitosis (Tuna). Post mortem the 
eruption fades, as the result of gravital ion of the blood from the anter- 
ior aspect of the body as it reclines upon the dorsum. 

Bacteria of small size and remarkable motility have been found 
in the blood by Coze and Felt/.; micrococci in the trachea by Klebs; 
spherical bodies in the breath of children, and post mortem in the 

lungs and liver by liraidw 1 and Yacher; and similar organisms in 

the vesicles and pustules of malignanl measles by Keating and For- 
mad. 2 Lessage, 8 studying the disease in 200 cases, often cultivating 
a delicate micrococcus on gelose, reports a production of something 
like the disease by inoculal ion. 

The disease LB chiefly one of infancy, probably because at that age 
there i- always the Largest number of individuals unprotected by 
previous attacks. In every case the malady results from contagion, 
mediate or immediate, from an infected human subject. It spares 
neither age nor -ex. though it is much rarer in advanced years than 

in other period- of life, probably because of the large number who at 

Mich period enjoy immunity. 

Diagnosis.- The diagnosis of importance is between scarlatina 
and variola. Typical cases with a well-developed eruption can 

1 Williams, "Bnbeola, Scarlatina, and Kourtli Disc-isc," Hrit. Mod. .lour., 1901, 
ii., p. 1797. 

*C/. Canon and Pielicke, Sternberg 'a tfagnan'a Bacteria, New York, 1884, 
i hull, de la Soc. m£d. dea Elfipit. Se Paris, March L5 20, 1900, 3 s., xvii., p. 282. 



RUBEOLA. 417 

scarcely be mistaken if the symptoms displayed are assigned their full 
weight. It would be useless, however, to deny the fact that atypical 
forms occur which have confused the most expert diagnosticians ; in 
all cases of doubt the prudent practitioner will refuse to decide as to 
the nature of the disease until unmistakable symptoms, in the lapse 
of time, have been declared. The resemblance between ill-developed 
measles and certain of the eruptions seen in varioloid is striking, and 
the greatest skill, at a given moment of time, will in cases fail to make 
a decision between the two. A distinctly crescentic character of the 
eruption, the prevalence of an epidemic, the discovery of Koplik's 
spots, the presence of catarrhal symptoms, the continuance of fever 
after the efflorescence is completed, the color of the eruption, and the 
discovery of the nature of the disease from which the contagion was 
derived, all point to the truth. From scarlatina measles is differ- 
entiated much more readily by the macular or papular elements of its 
eruption; by their cyanotic, darker hue; by their appearance to a 
marked degree upon the face ; and by the absence of the sore throat, 
tenderness of the neck, and characteristic " strawberry tongue," and 
usually intense febrile access of the first-named disease. From the 
various forms of erythema accompanied by fever, as well as from the 
medicinal rashes, insect-bites, and syphilitic eruptions, measles can 
be distinguished by the irregular temperature-record as well as by the 
character of the eruption. The diagnosis between rubeola and rotheln 
is given later. 

Treatment. — The treatment of measles should be limited to care- 
ful hygienic attention to the invalid, including a restricted "fever 
diet," and to the strictest isolation, disinfection, and ventilation, 
and to the use of only such medicaments as especially are indicated. 
The antithermic remedies employed in the general management of 
the febrile process may be required in special cases. 

In the way of local treatment the skin should be anointed with a 
bland, oily, or fatty substance, to relieve the pruritic sensations, espe- 
cially after sponging of the surface once daily with a weak alkaline 
solution, which may be used cool without fear of producing " reper- 
cussion" of the exanthem. The chamber of the invalid should be 
somewhat darkened for the sake of the eyes, but pure air should con- 
stantly be admitted. 

Prognosis. — The prognosis is in general favorable, but is of the 
gravest in special conditions. All the complications named above in- 
crease the gravity of the disease, which is also enhanced among men 
crowded together in camps, children in public charities, pregnant 
women, the cachectic and those greatly enfeebled from disease, very 
young infants, old men and women, and residents of islands that 
have been long unvisited by epidemics of the malady. 



27 



418 HTPBRAtMIAS AND INFLAMMATIONS. 

ROTHELN. 

• !.\. Rubeola Notha, Rubella, German Measles, Hy- 
bbid ob Bastabd Measles, French Measles, Epidemic 
Roseola. /'/•. Rubeole; Qer. t Rotheln.) 

Symptoms. Thia ia a disease which occurs in epidemics, sporadic 
cases arc not recognized. The contagiousness varies in different epi- 
demics. The period of incubation is usually from two to three weeks 
but the disease may develop twenty-four hours after exposure. 

Enlargement of the posterior cervical glands is one of the most 
striking features of the disease, occasionally glands in other parts 
of the body are enlarged. This symptom is not observed in measles. 
There is usually no fever; when such is present it only lasts for the 
first two days of the illness; in an average case the temperature runs 
from 100° F. to 102° F. though it has been known to reach 104° F. 
in rare instances. Prodromes, such as malaise, cephalalgia, articular 
pains, nausea, and vomiting are quite exceptional. 

The eruption is usually the first evidence of disease ; its poly- 
morphous character is the most striking feature; it may present the 
appearance of scarlet fever on one part of the body and of measles on 
another part; or in a given epidemic one patient may have a scarlatin- 
iform eruption and another patient a rash of morbilliform type. 

The eruption occurs for the most part in the regions affected by 
measles, first on the face and scalp, later on the neck, the trunk, the 
upper and finally the lower extremities, in the form of multiple, dis- 
crete, pin-point- to small pin-head-sized macules, but smaller than the 
lesions displayed in that disease, and decidedly lighter in color. The 
shade is from a rosy or pinkish to a crimson red, rarely lurid, never 
of dark mulberry or violaceous hue. This color at times will be per- 
ceptible beyond the line of the lesions as a delicate halo, a circum- 
stance which strongly distinguishes the exanthem from morbilli. 
The lesions, moreover, seldom are arranged in crescentic outline, more 
often being grouped in roundish or oval patches. Often, indeed, the 
elements of the eruption are discrete and disseminated, and after com- 
plete evolution may be elevated slightly above the general surface. 
The fauces occasionally are reddened in puncta. The eruption com- 
monly fades in from a few hours to one to two days, and there may 
be Blight resulting cutaneous desquamation. 

The objection 1 to regarding rotheln as a clinical entity has been 
answered by the observation of epidemics in wards full of patients, 
simultaneously affected and all presenting mild symptoms. 

Etiology and Pathology. — The disease occurs in epidemic form, 
i- distinctly infectious and contagious, attacks an individual but once 
in a lifetime, affords no immunity in subsequent exposure to either 
measles or scarlatina, and attacks usually young subjects. 

Diagnosis. — The epidemic character of the disease, its mildness, 

1 DUingham, Ajner. tied., 1908, \i.. p. 863; Griffith, Phila. Med. Jour., 1902, 
ix.. p.659. 



SCARLATINA. 419 

the sudden appearance of an eruption without prodromes, the transi- 
tory character of the fever, the adenopathy, its occurrence in children 
who have previously had measles, together with the character of the 
eruption as described above are the points on which to rely for 
the diagnosis. Erythema caused by gastro-intestinal autointoxica- 
tion must be considered. 

Treatment. — Kotheln should be treated by rest in bed, an abun- 
dant supply of fresh air, strict asepsis, and the usual diet of fever- 
patients. Medication by drugs rarely is indicated. 

SCARLATINA. 

(Scarlet Fever, Scarlet Rash, Canker Rash. 
Ger., Scharlach; Fr., Scarlatine.) 

The period of incubation of scarlet fever varies between twenty- 
four hours and six days, the average duration being about three days. 
The reason of this variation is to be sought, not in any changeability 
in the mode of evolution of the disease, but in the fact that its poison 
is less volatile and less rapidly dissipated than is that of measles, the 
result being that it may remain potential for longer periods in con- 
nection with articles through the medium of which it is transferred 
from one individual to another. This incubative period, like that 
described in connection with measles, may be unproductive of physi- 
cal symptoms, or may be associated with ill-defined malaise. 

Symptoms. — The prodromes are of importance in diagnosis. 
There is an abrupt onset to the disease. The attack begins with 
vomiting, a slight headache, or a characteristic sore-throat. In child- 
ren a convulsion is frequently the first symptom. On examination 
the patient is found to have a rather characteristic rapid and bound- 
ing pulse, an exceedingly dry skin, and a high body-temperature 
(102°-105° F.). Where the mouth is examined, the tongue is seen 
to have a creamy white coating through which the red filiform papil- 
lae protrude; this is the so-called "strawberry-tongue." The velum, 
the pillars of the fauces, the tonsils, and all exposed mucous surfaces 
are engorged, tumid, reddened, and often covered with deep reddish 
puncta, which represent hyperemia of the perifollicular tissues. 
In severe cases the mucous surfaces may speedily exhibit finger-nail 
to pigeon-egg-sized ashy ulcerations with a lurid halo at the periphery. 
On the first visit the physician should note the condition of the lymph 
glands ; those of the neck are usually somewhat enlarged, and those in 
the groin may be swollen. In children there may be syncope, delir- 
ium, convulsions, or when the toxaemia is intense the result may 
be fatal before the eruption appears. In some cases purpura which 
is frequently mistaken for hemorrhagic small-pox appears in this ful- 
minating form of the disease. This prodromal period usually lasts 
from twelve to twenty-four hours, though it may be prolonged for two 
days more. In this respect scarlatina is markedly distinguished 



420 EYPBBASMIA8 AND INFLAMMATIONS. 

from measles. This stage is terminated by the appearance of the 
exanthem, but the fever persists without abatemenl after the ex- 
plosion; and the other symptoms of the disease are then in no wise 
ameliorated. Authors describe three distinct types of the disease: 
the Bimple, the septic, and the toxic. 

The eruption in scarlatina usually spares the face, however much 
the lutier may display two damask-colored cheeks under the febrile 
flush, may become tumid with the hi 1 pumped through the throb- 
bing carotids, or even may exhibit :i few scanty lesions upon the fore- 
head and temples. About the mouth the integument is generally 
pallid; this is far different from the picture presented in measles 
The eruption thence spreads rapidly downward over the neck, the 
trunk, :m<l the extremities in symmetrical development, being often 
conspicuously prominent over the elbows, the backs of the hands and 
feet, and the belly. The rash is exhibited, first, in the form of light- 
or deep-red pin-head-sized puncta about the hair-follicles, closely ag- 
glomerated; and, second, in the form of a superadded erythema, giv- 
ing to the eye the impression of a diffuse reddish blush. The rash 
develops early about the neck and the clavicular regions, and it 
rapidly spreads to the trunk and extremities, including the dorsal 
surfaces of the hands and feet, attaining complete development in the 
course of the second day. It is then of a distinctly Bcarlet color, 
whence the disease derives its name in Latin, English, and German, 
a coloration frequently compared with the appearance of a boiled 
Lobster. Upon the limbs it often is developed in punctate form, 
while the occurrence of a diffuse scarier blush is perceived most dis- 
tinctly by the eye in the examination of the trunk, where the rash is 
Been to fade under pressure. In any event the erythematous blush 
commonly disappears before the individual elements of the rash are 
removed. The eruption can be made to disappear on pressure in the 
early stages of the affection. Drawing the finger-nail rapidly over 
the surface of the skin is followed by the formation of a whitish- 
yellow line, which persists for a time sufficient to enable one to de- 
scribe a letter upon the skin. This period of efflorescence lasts for 
from one or two days to an entire week, during which the febrile and 
other symptoms cont inue unabated. 

The fash usually persists at its maximum of development from 
one to three days, the concomitant Bymptoms continuing without 
noticeable abatement. Among the latter may he named the occur- 
rence of albumin in a urinary secret ion of diminished specific gravity, 
with occasionally the presence of epithelium, recognizable under the 
microscope a- derived from the lining membrane of the uriniferous 

1 ubules of the kidney. 

Saving attained it- apogee, the eruption in favorable cases be- 
gins to fade, the part first affected exhibiting earliesl a lighter shade, 
while the other pathological phenomena diminish in severity, the sore- 
throat, especially in ulcerated condition-, alone persisting. In from 
four to ten days longer the eruption disappears, leaving a brown-yel- 



SCARLATINA. 421 

low pigmentation of the skin-surf ace ; simultaneously the other symp- 
toms of the disease vanish. 

The desquamation which ensues as convalescence progresses is 
general, and is often proportioned in extent to the severity of the pre- 
ceding eruption, though it may be generalized after a well-nigh imper- 
ceptible exanthem. Desquamation is more pronounced and character- 
istic in scarlatina than in any other of the eruptive fevers. It may be 
superficial and furfuraceous in character, or the epidermis may fall 
in lamellated layers ; for example, the sheath of an entire finger, with 
the nail, or that of the entire palm. In this way sheets, ribbons, and 
shreds of the horny layer of the skin may fall from its surface and 
expose a new and often tender epidermis beneath. The hairs may 
simultaneously be shed. When this desquamation is finished the 
stadium of the disease may be regarded as concluded, the entire period 
lasting in uncomplicated cases from a fortnight to a month or six 
weeks. 

Septic (Anginose) Scarlatina is characterized by the gravity of 
the throat-symptoms. In such cases a parenchymatous inflamma- 
tion of the tonsils, velum, and fauces supervenes at an early period, 
with enormous tumefaction, involvement of the submucous tissue and 
neighboring glands, and ulcerative, suppurative, and even gangrenous 
complications which speedily may prove fatal. 

Toxic Scarlatina (Scarlatiniform Typhus; Fr., Scarlaiine Fou- 
droyante). — This severe type of the disease is that in which symptoms 
of typhus are pronounced. Here the patient may perish within a 
few hours after attack and before the eruption appears, exhibiting 
comatose or convulsive symptoms, indicating the profound influence 
upon the nervous centres of the intensely intoxicated blood ; or the 
eruption may appear ill developed, often livid, hemorrhagic, or petech- 
ial in type, and be followed by albuminuria, meningitis, diarrhoea, 
coma, and death. 

The Complications, Anomalies, and remote Sequels of scarlatina 
are so numerous as to furnish a vast array of facts for the study of the 
pathologist. The reader need merely be reminded in these pages that 
the usual incubative and prodromic stages of the disease may be brief 
as to time, or be followed so brusquely by eruptive phenomena as to be 
indistinguishable. The latter may also first occur upon the extremi- 
ties or trunk, and later on the neck and over the clavicles ; or at once 
cover the totality of the surface by a rapid explosion, or be extremely 
short-lived, or be altogether absent, or be unusually prolonged and 
visible for even a fortnight upon the surface of the body, appearing 
and well-nigh disappearing without appreciable cause. To a pro- 
portionate extent the stage of desquamation may be reached preco- 
ciously or tardily, and the exfoliating process tediously be prolonged 
and of intense type, jeoparding in this manner the future of the con- 
valescent prostrated by the fever which has passed or the sympathetic 
fever which may thus be awakened. 

The anomalies of the scarlatinal rash are numerous, but they de- 



422 HYPEREMIAS AND INFLAMMATIONS'. 

pend, in general, leas upon a variation in the intensity of the poison 
than upon the physical condition of the patient. Thus, the affected 
surface may be elevated slightly above the general level; there may 
be no coincident pyrexia; the akin may exhibit irregularly disposed 
mottlinga and maculations; the raah may be characterized by the oc- 
currence of miliary papules, minute vesicles, blebs, or purpuric les- 
ions, well defined against the general scarlet color of the skin by their 
violaceous shade ami due to cntaneonfl extravasation of blood. The 
rare bullous, pustular, and urticarial lesions which may appear upon 
the akin are accidental and bear no relation to the specific history of 
the dia 

Catarrhal and parenchymatous nephritis is justly dreaded during 
the desquamative period of the malady, when it may prove fatal after 
a relatively benignant manifestation of the disease in its prodromal 
and eruptive stages. Gastro-intestinal disorders may also prove 
dangerous. An otitis externa, media, or interna may perforate the 
tympanum, destroy the ossicles, induce caries of the mastoid process 
of the temporal hone, and prove fatal by the eventual production of 
meningitis or phlebitis. To this grave list of disorders which may 
complicate scarlet fever musl be added pneumonia, pericarditis, pleu- 
ritic peritonitis, chronic purulent nasal catarrh i which may result in 
caries of the nasal bones), destruction of the cornea as a result of 
severe keratitis, persistent adenopathy of the subcutaneous glands, 
and malnutrition in many forms, which may so impair the vigor of 
the constitution as to leave 'li<- Bufferer a physical wreck for the re- 
mainder of life. 

Etiology. — The disease is produced exclusively by contagion de- 
rived from the animal body affected with scarlatina, either mediately 
*>r immediately, and may occur as an epidemic. It attacks individ- 
uals of both sexes and all ages, children and infants more frequently, 
the aged more rarely, probably in consequence of their respective 
conditions as regards immunity conferred by a previous attack, since, 
in general, the disease occurs but once in a lifetime. Individual 
idiosyncrasy must account for the cases in which unprotected infants 
exposed to the disease fail to receive it, a fact noted occasionally in 
epidemics of all the exanthemata. The contagious element, which is 
volatile in its nature, seems to be most active during the eruptive 
stage of the disease. 

Pathology. Klein. Baginsky 1 Class 8 and Weaver 3 have studied 
the Streptococcus pyogenes which is usually present in scarlet-fever. 
h u now generally accepted that this microorganism is nol the cause 
of the disease but rather a secondary invader responsible for some 
of the consequent inflammatory and suppurative lesions. The micro- 
organism which is the causal agent has not been discovered; it is 
probably not a bacterium, liallory has described protozoon-like 

1 Berlin, klin. Wehneehrft., 1900, sxxvii., p. 588 and p. 618; Lancet, 1900, ii., 
p. 1284. 

- Med. Reeord, 1899, IvL, p. 880 and p. 518; J. A. M. A., 1900, xxxv., p. 799. 
•Jour. Med Reach., L908, Ix., p. 840. 



SCAELATINA. 423 

bodies found in the skin of four cases. Duval 1 Has confirmed his 
findings. The possibility of this protozoon being the cause of the 
disease is now sub judice. 

The cutaneous lesions of scarlatina, like those of measles, depend 
upon hyperemia due to vascular dilatation of blood- and lymph-ves- 
sels, and a moderate degree of exudation. The latter, when it 
occurs, is limited for the most part to the rete and papillary layer of 
the corium. There is no diapedesis of leucocytes, though clusters of 
connective-tissue cells may be demonstrated about the papillary loops 
of the capillaries. Mast-cells and mitoses appear when desquamation 
begins ; plasma-cells are absent. According to von Jiirgensen, the re- 
sult is a vasomotor paralysis of the peripheral vessels. The signs of 
the disorder are not apparent in the dead body unless there have 
been exudation of blood and the consequent formation of petechise. 

According to TTnna, the epidermis, when the disease is fully 
developed, is the seat of a parakeratosis productive of scaling, while 
the prickle-layer shows neither oedema nor emigration. In the cutis 
there is a maximum of congestion without distinct osdema. The 
general vasomotor disturbance leading to a species of vascular paraly- 
sis is supposed to be due to changes in the nervous centres produced 
by the disease. 

Diagnosis. — The diagnosis of scarlatina from measles, rotheln, 
erysipelas, and the erythemata in general is established readily. The 
sore-throat, intense fever, punctiform scarlet rash reaching to the 
border of the inferior maxilla, and the distinct, whitish-yellow line 
traceable by the finger-nail when passed rapidly over the surface, are 
. all characteristic. In measles the macular character of the rash and 
its crescentic arrangement, in connection with the catarrhal symptoms 
will usually be recognized. From erysipelas scarlatina can always 
be distinguished by the absence of the peculiar, shining, smooth, or 
glazed and tumid condition of the affected area. From all other 
rashes scarlet fever can be distinguished by the pyrexic symptoms and 
resulting desquamation. For the distinction between scarlatina and 
erythema scarlatiniforme the paragraphs devoted to a description of 
the malady last named may be consulted. 

Great care should be taken not to confound the drug-rashes having 
a scarlatiniform appearance with the specific disease under considera- 
tion. Thus, belladonna, in doses of 1 minim of the tincture every 
hour to the extent of four doses, has produced an abundant scarlatini- 
form eruption in children, a diagnostic point of importance in view of 
the fact that the drug named has been employed as a prophylactic 
against the disease. For eruptions of this sort due to quinine and 
other drugs the reader is referred to the pages devoted to Dermatitis 
medicamentosa. 

Treatment. — The modern treatment of uncomplicated scarlatina 
is antiseptic and expectant, after provision is made for an abundant 
supply of fresh air, disinfection, a proper regulation of food and 

1 Virchow's Arehiv, 1905, clxxix., p. 485. 



424 HYPEREMIAS AND INFLAMMATIONS. 

drink, and the Local use of baths, tepid or < 1. for the purpose of re- 
ducing the body temperature. After these baths the skin should be 
anointed freely with a fatty Bubstance, such as cold-cream salve, 
scented almond- or olive-oil, or with vaselin. These inunctions are 
do! only grateful to the patient, but they also reduce the body-temperar 
tun- to a Blight degree. All treatmenl other than that suggested above 
pertains to the field of general medicine, and should be Limited to the 
special conditions presented in each case. Such treatment includes 
the management of disorders of the eye, ear, throat, kidneys, and 
• •ther viscera, the involvement of which constitutes a complication 
of the disease. 

Prognosis. The prognosis of the malady should always be es- 
tablished with reserve. It is Largely based upon the relative intensity 
of the Bymptoms, the vigor and age of the subject, and the presence or 
the absence of serious complications. Albuminuria is rarely absent, 
and i- not per &< alarming; bul anasarca and other evidences of pro- 
found interference with the renal function are to be assigned due 
weight. En general, it may be said that a high range of temperature ; 
early and ulcerative throat-lesions; the puerperal state; tardy develop- 
ment, rapid and untimely disappearance, or undue prolongation of the 
exanthem : and its admixture with petechias to such an extent as to in- 
dicate extensive hemorrhagic extravasation, are all formidable Bymp- 
toms. Finally, it must not be forgotten that the mildest and simplest 
forms of the disease, after the fastigium is passed and convalescence 
i- actually established, may terminate fatally by the supervention of 
uraemia, cerebral paralysis, or even meningitis, consequent upon sec- 
ondary changes in the middle or internal ear. 

VARIOLA. 
I i,:it.. varus, a blotch.) 

iSm.u.I.-Imi.x, Till-: Pocks. (Itr., I !l..\ TTERN, POCKEN J /*V., PETITE 

Verole ; Hal., Va.i i olo. | 

The variations of variola as to the severity, character, and dura- 
tion of its symptoms are so great as to preclude complete description 
of this malady within the limits here assigned. The following para- 
graphs are therefore devoted to a sketch merely of its more com- 
monly recognized characters. 

Initial Rashes ( Variolous Erythema; Variolous Roseola). — These 
may be either (a) erythematous in character, and general or partial; 
or (b) hemorrhagic, in the form of pure petechia' or of admixtures 
of petechia] and erythematous blotches. 

On the second and third days there appears, in some cases, espe- 
cially in menstruating women and in young subjects, a cutaneous 
efflorescence, the significance of which may be misinterpreted, thus 
Leading to error- in diagnosis. To ETebra we are indebted for its dis- 
tinct recognition as a cutaneous prodrome in variola. The interprets- 



PLATE XII 









' 


If- - 


, «» ^H 




, ^ 








** 








^HH 








, ;-. - 








yj 


;''' 


9|H^^9H^^H 


'. :-^ 


^ ■ ■'■.."- ... 




in . 


JSL, 






Y V " v - ... W 



Variola, eighth day of eruption. (Heman Spalding.) 



PLATE XIII 




Variola, eighth day of eruption. (Heman Spalding. 



VARIOLA. 425 

tion of this exanthem is a matter of special importance to the diagnos- 
tician, as many have been deceived respecting its nature and signifi- 
cance. It is characterized by the occurrence of irregularly disposed 
and distinctly outlined maculations, puncta, striae, streaks, or a diffuse 
blush of bright or lurid reddish hue ; the invaded integument being 
at times slightly tumid, and thus elevated above the general level. 
The affected part may also be the seat of moderate pruritus. The 
blush may fade under pressure, but rarely does so perfectly. One 
cannot by the finger produce upon it a visible whitish spot. The rash 
may be diffused widely but occurs most often about the groins, the hy- 
pogastric region, the pubes, and the inner faces of the thighs ; and on 
examining these parts the physician will usually discover the evidence, 
in adult women, of recent or present menstruation, or of the puerperal 
state. It occurs also about the axillae, the extensor faces of the larger 
and smaller joints, and the lumbar and clavicular regions. Often a 
broad area of the integument in these parts may exhibit a sheet or 
mask of dull crimson erythema, upon which may form pin-head- to 
bean-sized, dull-reddish papules, not losing their color under pressure, 
or more rarely petechias, vesicles, and wheals. All these are precur- 
sory phenomena, and are not transformed into characteristic variolous 
lesions. They fade almost completely before the latter appear. 
Rarely, a few scattered papules may be distinguished upon the face 
and the arms before the variolous erythema fades. Often the papules 
in full development are even less profusely displayed on the site of 
the precedent efflorescence. The latter need not be necessarily re- 
garded as a symptom of portentous gravity. The entire surface of 
the belly may be covered with a uniform erythematous blush of dull- 
crimson hue, followed by confluent variola, and the patient ultimately 
recover. The physician, then, confronted with a deep-red erythema 
of the regions named, especially of the groins, the lower part of the 
belly, and the thighs of a menstruating woman affected with high 
fever, nausea, vomiting, and lumbar pain, should invariably suspect 
the presence of variola. 

The vividly red or empurpled rashes of hemorrhagic type occur 
most frequently in the localities named above when the disease as- 
sumes a grave aspect, as in hemorrhagic variola. 

Small-pox Eruption. 1 — The period of the eruption in variola is 
characterized, at its earliest, by punctiform, subcutaneous discolora- 
tions which photography alone can reveal. Commonly the patient 
will be seen on the morning of the third or oftener the fourth day 
with the face and scalp covered with pin-head-sized and larger, firm 
conical papules, the touch of which to the finger suggests to most 
English observers the feeling of shot embedded within the skin. 
Later, these papules develop upon the trunk and limbs ; and in well- 
marked cases every portion of the body-surface is invaded, including 
the palms and soles. The lesions may be surrounded by a narrow 

1 Cf. Discussion on small-pox before Amer. Derm. Assoc, May, 1901, J. C. D., 
1901, xix., p. 484. 



ii"; 



11 YPBRSMIA& AND IS FLAMMA TI0N8. 



rosy areola apon the trunk. They may be unproductive of subjective 
sensations or be slightly tender. 

A- a rule, there la complete defervescence when the exanthem ap- 
the patient expert ucing such relief thai if an adult has chanced 
not to view his face in a mirror nor to be informed <>f his appearance 
by those in attendance upon him, he often will regard himself as eom- 
pletely relieved of his three .lays' illness. In other eases the febrile 
symptoms persist with a lowered temperature. 



Pio. 




Vertical section of pustule at the beginning of pustulatlon : a, umblllcatlon at the 
Bite of an excretory canal ; b, reticulum within the epidermis ; c, reticulum of smaller 
meshes containing lymph- and pus-globules. (After RzHDFUIBCH.) 

During the first two days of the eruptive period the papules in- 
crease in number and become correspondingly agglomerated ; while 
those of earliest appearance become transformed into vesicles con- 
taining a translucent serum, the roof-wall of many of them exhibiting 
an umbilication. This umbilication of the vesicle, though not in- 
variably present, is characteristic, and slightly different from that 
observed in bullous and pustular lesions. The central depression is 
disproportionately large, and about it the yet undistended epidermis 
is often irregularly puckered or fluted. Even in this period the lapse 
of a few hours will produce a lactescent appearance in the formerly 
translucent contents. The mucous surfaces adjacent to the skin may 
similarly be involved. 

From the sixth to the twelfth day the transformation of these 
lesions inlo pustules is effected, the process beginning, as in all the 
metamorphoses of the disease, in the vesicles of greatest age, those, 
namely on the face and upper portions of the body. The lesions 
simultaneously enlarge until they are of the size of an average pea, 
are surrounded with a distinctly ovoid areola, and, when fully dis- 
tended, rupture the centrally placed filament which holds down the 
roof-wall; consequently the umbilication of the pustules is lost. The 
integum< ut upon which they develop becomes visibly tumid. With 



VAEIOLA. 427 

this process of suppuration is awakened the so-called " secondary 
fever," a pathological feature evidently not essential to the disease, 
as it does not occur in mitigated cases. This secondary fever is 
born of the extensive suppuration occurring in the skin and other 
organs, and may be symptomatic, sympathetic, or septicemic in 
character. It thus varies in different cases with the character and 
severity of the process by which it is excited, being transitory in 
mild cases, and in others terminating only with death. At this time 
the patient is usually in a most distressing condition. The skin of 
the face and of other attacked regions is swollen, thickly covered with 
pustules, and the features indistinguishable in the tumid and closed 
lids, the oedematous lips, disfigured nostrils, and pus-obstructed mu- 
cous outlets. Deglutition becomes painful and often impossible, the 
saliva flows from the lips, and the mucus from the nares dries with 
the pus upon the exterior of the visage. The pustules recognized 
upon the integument are represented also in the gastro-intestinal tract. 
In an autopsy of a patient dead at this stage of the disease the entire 
canal from the mouth to the anus, as also the genito-urinary and 
respiratory passages, may be completely covered with closely agglom- 
erated and well-distended pustules. The career of those within 
the mouth can usually be studied by eye-observation. In this sit- 
uation they rapidly lose their epithelial roof-wall by reason of the 
heat, moisture, and friction to which they are subjected, and then ex- 
hibit a reddened and excoriated surface, over which there is re-forma- 
tion of the epidermal layer. Gangrenous complications are rare. In 
this condition women who are pregnant frequently abort or miscarry, 
the foetus, coming into the world exhibiting cutaneous symptoms of 
the disease. 

Between the thirteenth and fourteenth day desiccation begins, 
and is usually completed within from ten days to a fortnight; 
the pustules rupture, and the exuded pus concretes into yellowish 
or brownish, rarely blackish crusts, or the latter are formed 
by the desiccation of the entire envelope and contents. The pulse 
usually at the same time diminishes in frequency and secondary 
defervescence occurs, the tumefaction of the integument decreases, 
and at times the peculiarly characteristic and often intolerably fetid 
odor from the patient is less perceptibly exhaled. In from four to 
six weeks the course of the disease is completed. The immediate 
traces of the eruption are purplish and violaceous pigmentations, 
which slowly disappear. When cicatrices result they are slightly de- 
pressed, at first of a dull purplish hue, later dead-white, lustrous, usu- 
ally symmetrical in disposition, and most distinct upon the surfaces 
exposed to the light and air, such as the face. Though persistent, 
they are rendered somewhat less deforming in the progress of 
years. When closely set together they produce a characteristic ridged 
and corded appearance, due to the elevation of narrow bands of unaf- 
fected integument between the depressed surfaces of scars. The 
several departures from the pronounced type of the disease described 



■\-^ 



HYPEREMIAS AXI> INFLAMMA TI0N8. 



above present variations differing widely from the mosl benignant 
forms. Brief reference only can be made to these variations. 

Varioloid. — Varioloid, whether occurring after vaccination or not, 

i- a modified type of variola. With it sh<.ul«l be classed all those 
forma of the disorder occurring in the human subject, and described 
by authors under the titles " wart-pox," " horn-pox," variola siliquosa, 
miliaria, verrucosa, crystallina, cornea, etc. In these cases there may 
he a severe prodromic fever and a scantily developed exanthem; 
rapid involution of Lesions; abortion of the latter in any of their sev- 
eral stages from papule to crust; absence of secondary fever: trans- 
mission of the disease in a mild or mitigated form from one individ- 
ual to another, so that an entire community, vaccinated and unvacci- 
uated alike, may suffer from an epidemic disorder of this moderate 




Vertical section of one-half of an undeveloped variola-pustule: a, old epidermis; 
'/ epltbeiia ol rete above the alveoli; <■. new-formed epidermis; </, alveoli filled with pus- 
globules; g, Battened and infiltrated papilla- lying beneath the pustule. (After 
Arsfirz and BASCH. I 



grade without the occurrence among them of a single case of typical 
variola. It i- scarcely necessary to add thai a patient with varioloid, 
especially during an epidemic, may transmit to the unprotected a 
malignant form of the disease. 1 

Hemorrhagic Variola (Black Small-pox, Variola Nigra Maligna), 
fortunately rare and confounded in the past with "black measles," 
i- a formidable condition, viewed from any point. 

The disease is developed in two fairly distinct types: the one pur- 
puric, most often seen in subjects debilitated by alcoholism, by en- 
feebling maladies in infants, and by the puerperal stale in women; 
the other shows pustular lesions. 

When cutaneous hemorrhages occur during the course of small- 

1 For a consideration of the symptoms and diagnosis of modified small-pox as it 
h,-i s appeared in recenl epidemics, sec Welch, Phila. Med. .lour., L899, i\., p. 973, 
and paper by me published by Dlinoia state Board of Health. L900; 



PLATE XIV 




Variola, sixth day of eruption. (Heman Spaldin< 



VAEIOLA. 429 

pox they do not necessarily indicate that the case is one of so-called 
varioliform purpura, since these extravasations may be accidents of 
the pathological process. In this malignant form of the disease, 
against the ravages of which vaccination often presents but a feeble 
barrier, the prodromic stage is followed by a deep purplish redness of 
the surface which is characterized by pin-head- to split-pea-sized, firm, 
closely set papular lesions, suggesting the occurrence of measles in a 
peculiarly severe form. The febrile, nervous, and other symptoms 
of the disease are proportionately intense. Ecchymoses appear upon 
the conjunctival membrane. Gradually the color of the exanthem, 
that at first disappeared under pressure, refuses thus to yield and 
assumes a bluish-black shade. Ecchymotic patches may be inter- 
mingled with the papules, rapidly widening to palm-sized and larger 
areas. The mucous surfaces share in these colors, being also infil- 
trated with effused blood, and the muco-cutaneous orifices are crust- 
covered and exhale an extreme fetor. Blood may escape from the 
bowels, bladder, mouth, or vagina. Signs of grave systemic and vis- 
ceral complications are always present. Vesiculation, pustulation, 
and the typical transformations of variolous lesions may be present, 
the blood in most cases becoming extravasated at the base or border 
of the lesions interspersed with petechise. In the few cases observed 
by us death speedily supervened, either from shock, coma, hemor- 
rhagic infarction of the lungs, or rapid exhaustion. Intermediate 
forms between hemorrhagic and true variola are described, in which 
forms the pustules occurring in the variolous type of the disease 
merely fill with blood in consequence of accidents possessing a purely 
local significance. 

Confluent Variola, — Confluent variola is another severe form, less 
malignant, however, than that just described. It is characterized 
by intensity of the prodromic fever, which often scarcely abates with 
the appearance of the exanthem. The latter is developed in deeply 
implanted, firm papules, closely set together, succeeded by vesicles 
and pustules, which, as they enlarge, fully occupy the entire sur- 
face of the integument, and accomplish a perfect coalescence. In 
well-marked cases there is scarcely a pinhead-sized area of the entire 
surface of the body that is not invaded. The tissues become enor- 
mously oedematous ; the deformity of the face renders the features 
indistinguishable. Hemorrhagic pustules and even patches of a gan- 
grenous pulp may be intermingled with sheets of suppurating sur- 
face. Phonation, respiration, and deglutition are impeded propor- 
tionately or are subverted absolutely by the tumefaction and sup- 
puration of the mucous membranes of the respiratory and gastro- 
intestinal tracts. When the patient survives until the stage of desic- 
cation is reached, the body presents a revolting aspect. A thick 
brownish or blackish-brown mask envelops the swollen head, trunk, 
and limbs, and the odor exhaled from the body is intolerably repul- 
sive. All the systemic phenomena are proportionately grave, and 
are accompanied by one or more of the complications of the malady — 



430 HYPBRMMIAB AND INFLAMMATIONS. 

pneumonia, pleuro-pneumonia, albuminuria, diarrhoea, various motor 
and sensory paralyses, furuncles, and subcutaneous abscesses. The 
eyes may Buffer from pustular and ulcerative changes in the con- 
junctiva, cornea, and deeper tissues, with resulting inflammation of 
every grade to panophthalmia and consequenl Loss of vision. Often 
the patients, with surprising powers of resistance, will survive until 
extensive sheets of crusts have fallen from the skin-surface, and then 
perish alowly in a typhoid condition with low remittent or continuous 
fever. Every such case does not, however, terminate fatally. Both 
adults and children may rally from the severest form of confluent 
variola, and afterward enjoy vigorous health. 

Symptoms. The period of incubation of the unmitigated disease 
varies between five and twenty or more days, occupying usually 
twelve days or a fortnight. It is characterized by the peculiarities 
of that period recognized in all the exanthemata, there being few 
and insignificant or no evidences of physical discomfort. The pro- 
dromic stage is ushered in generally by a vespertine chill, succeeded 
by fever, with a temperature rising to 104°-10f>° F., which is com- 
monly associated with severe and characteristic pain in the loins, 
headache, epigastric pain, nausea or vomiting, and occasionally in 
young subjects with delirium and convulsions. The fever continues, 
with alternations of exacerbations and partial relief, or sensations of 
chilliness, during the second and third days. At the same time there 
may be faucial hyperemia and moderate dysphagia. Occasionally, 
before the cutaneous exanthem appears, minute reddish papules may 
be recognized upon the buccal membrane. 

Etiology. — Variola is always the result of mediate or immediate 
contagion. It is a disease both contagious and infectious, being 
often epidemic and transmissible by volatile emanations from the vic- 
tims of the disease. It is also artificially inoculable. When trans- 
mitted by the latter process its period of incubation is somewhat 
shortened, and often its successive manifestations become less formid- 
able. The history of inoculated human variola has received, how- 
ever, bul little attention during late years, since the practice properly 
has been forbidden by law. The disease is, to a certain extent, 
transmissible from man to the lower animals, and the reverse. It 
attacks individuals of both sexes and all ages, including the foetus 
in utero, which may be ushered at an untimely hour into the world, 
macerated, or recently dead, and covered with the lesions of variola. 
The disease in the larger cities is decidedly more frequent in winter 
than in summer, possibly because in the colder months the opportuni- 
ties are greater for spread of the contagion in artificially heated 
dwellings in which numbers of individuals are crowded together. 
[slanders, long unvisited by an epidemic and unprotected by vaccina- 
tion, may Buffer equally in the summer season. 

Pathology. The Latest investigations on the pathology of variola 



PLATE XV 




Variola, tenth day of eruption. (Heman Spalding.) 



PLATE XVI 




Wf:, 






• _ * -Til 



*.% 







Variola, thirtieth day of eruption. (Heman Spalding.) 



VABIOLA. 431 

have been made by Councilman, Magrath, and Brinckerhoff. 1 These 
observers believe that the peculiar inclusions within the epithelial 
cells, previously described by Guarnieri in 1892, and after him by 
others, sustain relations to the etiology of the disease. 

In the lower layers of the epithelia structureless bodies are seen 
from 1 to 4 /a in diameter, lying in the intercellular vacuoles which 
at first are scarcely larger than the contained bodies. The vacuole, 
however, increases in size as these bodies become larger, more defi- 
nitely granular, and more distinctly located. Segmentation of the 
mass occurs later with the formation of round bodies about 1 /* in 
diameter. These intercellular bodies are regarded as living organ- 
isms. 

When segmentation is completed, small, round, oval, or ring-like 
bodies appear in the nucleus which increase in size, acquire a definite 
structure, and consist of a series of vacuoles around a large central 
vacuole, one or more appearing at times within a single nucleus. 

The intranuclear body is believed to be an advanced stage of the 
development of the intracellular body, springing from the spore- 
like elements produced by segmentation of the intracellular body, 
which pass into the nucleus. The spores formed by its segmentation 
are probably the " true infecting material of variola." Inoculation 
of rabbits with the contents of variola-pustules has given origin to 
lesions in which both the intracellular and the intranuclear organ- 
isms have been recognized. It is believed by these observers that in 
small-pox the parasite passes through two cycles, but that in vaccinia 
the primary cycle alone is traversed. The spore-like body formed 
in this cycle, when introduced into an unprotected human subject, 
produces vaccinia. 

Coze, Feltz, Baudouin, Luginbiihl, Weigert, Hallier, and Cohn 
recognized both bacteria and micrococci, in the blood of variolous 
patients. Cohn 2 regards these parasites as instances of a "twin 
race" of Micrococcus vaccinae discovered in vaccine-lymph. The 
secondary fever of the disease is without question septicemic, and 
is due to pus-cocci and their toxines. 

According to TJnna, the main distinction between the vesicle of 
varicella and that of variola lies in the slow growth of the one and 
the prompt suppuration which is added to the fibrinoid degeneration 
of the other. The epithelium of the lower prickle-layer undergoes 
speedily " ballooning colliquation " not only at the apices of the pap- 
illae, but also in the depths of the ridges. A gradual division of the 
vesicle follows into an upper and a lower story, with a lateral exten- 
sion of the cavity in the upper prickle-layer, a somewhat characteris- 
tic oedema, and mitotic proliferation of the semisolid cushion below. 
The umbilication is produced less by the action of centrally placed 

1 Jour. Med. Resch., May, 1903, ix., p. 372. See also Funk, B. M. J., 1901, i., 
p. 448 (abstr. in Arehiv, 1903, lxv., p. 290) ; Stokes, Bull. Johns Hopkins Hosp., 
1903, xiv., p. 214; Sanfelice and Malats, Arehiv, 1902, Ixii., p. 189; Thompson, 
Jour. Med. Resch., 1903, x., p. 71. 

2 See Magnan, loc. eit., p. 411. 



4f.L' HYPBRJBMIAS AND INFLAMMATIONS. 

epithelia acting as guy-ropes than by the enormoua force of the exu- 
dation at the periphery in contrast with the Blight activity of the cen- 
tral parts, a- a result of which the latter are simply "left behind." 
Gradually there follows a dense collection of plasma-cells in the 

adventitial sheaths of the hi l-vessels. The latter subsequently 

dilute, and the line of demarcation between the cutis and rete becomes 
well-nigh indistinguishable on account of the stream of leucocytes 
thither. Sealing begins at a later stage by the formation and 
gradual contraction of a thin layer of epithelial cells lying close to 
the connective tissue and extending from all -hie- beneath the pustule. 
Diagnosis.— The difficulty attending the diagnosis of variola in 
it- prodromic and earliesl eruptive Btages, from measles, is considered 
in the description of the latter disease. The general demand, indeed, 
upon the physician for an exact and definite diagnosis of every case 
before it- complete evolution, i- founded upon an erroneous conception 
of possibilities, and the sooner this generally is recognized the better. 
A delay of even a few hour.- will often verify or remove a BUSpicion. 
Fully as much mortification on the part of the physician and damage 
to the best interests of the patient may result from an error in one 
direction as in the other. The wisest course in every doubtful case 
i- to adniii tlie doubt and to visit the patient frequently for the pur- 
pose of observing the development of the disease until thai doubt 
is removed. Typical cases of variola are recognized with ease from 
the character of the symptoms presented. Measles and scarlatina 
resemble variola only during the period in the last-named disease 
when the variolous rashes are present. The symptoms of diagnostic 
importance at this period are, the presence or absence of fever, of 

catarrhal symptoms, of lumhar pain, the site of first appearance of 
lesions, and the duration of the disease. [mpetigo, and, in particu- 
lar, impetigo contagiosa, is a non-febrile, almosl never generalized, 
affection of the face and hands — in point of fact a finger-nail-filth 
disease. Its particular lesions are relatively few, and not umbili- 
cated. Varicella (chicken-pox) i> characterized by the occurrence 
of the thin-walled, translucent, superficially situated vesicles first 
developing on the trunk, later on the face, with a mild fever accom- 
panying instead of preceding the rash. They are never indurated 
nor umbilicated. Accidental and secondary eruptions which may 
he present are recognized by the history and features of each. 3 Syph- 
ilis and acne are always distinguished by the absence of fever ami 

their relative chronicity. 

Treatment. The treatment of variola should, in general, he lim- 
ited to the indications presented in each case. No remedies can he 
employed which have the least power to aborl the disease. Kaposi 
call- attention to the striking fact in this connection, that syphilis, 
for many of the manifestations of which mercury is a specific, is a 
disease the second incubation-period of which is measured by weeks. 

ami vet neither hv excision of its initial sclerosis nor by mercurials 
1 Behamberg, .1. I '. D., L903, nri., p. 215. 



VARIOLA. 433 

can the subsequent manifestations of the disease be completely pre- 
vented. Certainly no specifics are recognized as of value in variola. 
The patient should be kept in a relatively dark room with an abun- 
dant supply of fresh air of a uniform temperature, and antiseptic 
solutions should constantly be at hand into which all the ejecta are 
received immediately. He should be given ice when this is accept- 
able to the palate, cool water ad libitum, and his strength should 
sedulously be supported by a liquid animal diet. The body may be 
sponged with or bathed in cool or tepid water as often as is grateful 
to the patient. In severe or confluent cases the immersion of the 
body in the continuous warm water-bath is followed. by brilliant re- 
sults in hastening the desiccation and fall of the crusts and subse- 
quent repair. A bath of this character given for merely two or three 
hours in the day is often of great value. With and without these 
external measures gargles of potassium chlorate, myrrh, honey, or 
carbolic acid will be found acceptable to the mouth and palate. The 
constant attention of an efficient nurse bestowing assiduous care upon 
the mouth, the skin, and the eyes may be regarded as an essential 
part of all sound treatment. 

With a view to the prevention of pitting, no measures of a thera- 
peutic character will prevent the occurrence of a distinct cicatrix 
whenever pus has eroded or otherwise destroyed the integrity of the 
papillary layer of the corium. Every effort, therefore, should be 
exerted to prevent extension of the suppurative process to the true 
skin. The following measures have approved themselves as of prac- 
tical value : First, the sick-room should be moderately darkened and 
yet be amply provided with fresh air. Second, a solution of pure 
sodium hyposulphite should be administered night and day in the 
dose of from 15 to 20 grains (1.— 1.3) every three or four hours. 
Salol, 1 iron, strychnine, quinine, digitalis, and opium, are indicated 
at times. The variolous lesions pursue a milder course under this 
internal treatment, and in some cases even the vesicles shrivel before 
pustulation is fairly begun. Third, the skin of the face, after spong- 
ing with a weak formalin lotion, should be anointed with a bland 
fatty substance such as vaselin, almond-oil, or fresh lard, and over 
the unguent may be laid silk-enveloped compresses, dipped in tepid 
weak solutions of carbolic or boric acid, or of thymol. The unguents 
thus employed are medicated at times with boric or carbolic acid, 
zinc oxide, resorcin, bismuth, sulphur, or other ingredients. The 
anointing of the surface before the application of the lotion is 
commonly more grateful to the patient, but the skin may be moistened 
with the aqueous lotion alone. Here, again, the assiduous attention 
of the nurse is a matter of importance. The powder of europhen 
topically is applied often with advantage. 

The edges of the eyelids should daily be anointed with freshly 
prepared cold-cream salve. Puncture of the cornea may be required 

'Begg, Scot. Med. and Surg. Jour., 1900, p. 222 (abstr. in B. J. D., 1900, xii., 
p. 184). 



434 HYPBRJSMIA8 AND INFLAMMATIONS. 

for the relief of hypopyon. Diarrhoea and other Bymptoms of vis- 
oeral derangement Bhonld be relieved by appropriate medication. As 
a rale, the administration of narcotics for the relief of pain is ob- 
jectionable. Throughout the conrse of the disease the Btrength of the 
sufferer Bhonld be supported by a generous use of animal broths or of 
milk: in typhoid conditions a judicious employment of stimulants 
may be necessary. 

The red-light treatment of small-pox devised by Finsen has been 
tried in a considerable number of cases with excellent results. 1 
In America the method has received little attention. A few ob- 
servers have reported failure with the treatment, but in these in- 
Btances it i- not clear that the technique was carried out properly. 

The treatment is based on the principle of excluding the chem- 
ically active raya from the skin of the affected patient. For this 
purpose the subject is placed in a room to which no light is admitted 
that is n«>t first filtered through red glass or other material that will 
effectively shut out all the chemical rays. As a control-test, sensi- 
tize.! photographic plates are hung in the room, and if they at any 
time show the influence of white light the technique is not perfect. 
Finsen states that "when the patient comes under treatment early 
enough, before the fourth or fifth day of the disease, suppuration 
of the vesicles — even in unvaccinated persons and in cases of con- 
fluent small-pox — will be avoided, with one exception out of about 
seventy. . . . Should the patient come under treatment after the 
fifth day of the disease, it is uncertain whether suppuration can be 
avoided." 

This method apparently has prevented suppuration, secondary 
fever, ami scarring, in more than 100 cases, ami is certainly worthy 
of thorough trial. 

Prognosis. — The prognosis of variola is largely dependent upon 
the degree of protection conferred by previous vaccination. In- 
dependent of vaccination, the age and vigor of the patient, the pres- 
ence or absence of an epidemic of severe or mild type, the extent of 
the eruption, and the character of the surroundings of the patient 
are elements of prime importance. Very yonng and aged subjects, 
women pregnant or in the puerperal state, and, as Hebra has shown, 
ihose who have suffered from a previous attack of the same disorder, 
are all unfavorably disposed with respect to the final result. Con- 
tinent and hemorrhagic forms of the disease are, naturally, the 
gravest Unmitigated variola, under the most favorable circum- 
stances, i- one of the greateal scourges of humanity, and as such will 
probably always destroy a frightful proportion of its victims. At 

1 Phototherapy, tninsl.it.. I from t lie German by J. H. Sequeira, London, 1901. 
Brown, Brit. Med. Jour., L903, ii., p. L409; Naunvn, ITnterelsiissiseher Arzteverein, 
Bits. 26 .timi. L903 (al.str. in Munch, med. Wchnschrft., 1903, L, p. 1360); Oepray, 
.lour. in.'-. I. de Bruxelles, L903, \iii., p, 69; Bmmerson, Med. Times and Bosp, Gaz., 
1903, xxxi.. p. 419; Caraua, II Morgagni, i.. No. I (abstr. in Monatahefte, 1903, 
rxxvi, p. 886); blanch, med. Wehnsenrft., 1908, L, p. 1S10. 



VARICELLA. 435 

the same time the conscientious physician needs to be impressed 
with the fact that, under the most discouraging circumstances, the 
patient, disfigured to the greatest extent by an envelope of blackened 
crust, and in a state of extreme physical prostration, with many of his 
bodily functions almost completely suspended, may even from the 
midst of such peril be won back to life and vigor. The assiduous 
attentions of a skilful nurse, guided by the inspiring presence and 
councils of a physician who is himself fearless of the malady, will 
often achieve the result. Upon the latter point it is interesting 
to note that physicians in active practice who do not hesitate to ex- 
pose themselves freely to the disease in the discharge of the duties 
of their profession rarely suffer in their own persons. 

VARICELLA. 

(Chicken-pox. Ger., Spitzblattern, Wasserpockejst ; 
Fr., Variolette; Ital., Moroigeione.) 

Symptoms. — After an incubative period lasting from ten days to 
a fortnight the first manifestations of the disease appear. This 
may be a prodromal erythema of which Anthony 1 has reported two 
cases. This eruption is the first evidence of disease ; it appears sud- 
denly, is generalized, and resembles scarlet fever but is less punctate, 
although usually it is quite distinct. The patient has watery eyes as 
in measles, a symptom never seen in scarlet fever. In some cases 
where the patient is stripped one or several umbilicated varicella ves- 
icles may be found on the body. The temperature is quite high 
(104° F.), still the patient does not impress one as being seriously 
ill. Both the erythema and the temperature disappear in from twen- 
ty-four to forty-eight hours and the patient is found to exhibit the 
typical varicella eruption. The patients are usually children, who 
may suffer from fever of a moderate grade (99°-100° F.), lasting 
from a few hours to two or three days, after which defervescence is 
commonly complete. With the onset of the fever or even without, 
the rash appears, first on the head and trunk, in the form of rosy 
macules or slightly elevated lesions lacking the characteristic " shot- 
like " feeling of the variolous papule. These macules rapidly be- 
come vesicular, the lesions being pin-head- to pea-sized, rounded or 
oval, well-projected from the surface, limpid, superficial in situation, 
differently shaped from variolous lesions, and almost never umbili- 
cated, puckered, or "fluted" as in small-pox. The macules appear 
in successive crops, often first over the upper posterior aspect of the 
trunk, where the typical evolution of the disease is best studied, and 
then the elements of the eruption are surrounded often by a faint 
pinkish or reddish halo. Their contents become cloudy or lactescent 
rather than puriform, and they desiccate as early as the second day, 
forming thin, light, superficial crusts. The lesions may be abundant 

1 J. CD., 1906, xxiv., p. 68. 



4::o HYPEREMIAS AND INFLAMMATIONS. 

in one region, as, for example, over the back or the chest, but are 
both abundant and generalized and are invariably discrete, 
never confluent They rarely occupy the palms and soles; and 
the vesicular Lesions may develop as such, or spring from the macules, 
the Latter, however, nol invariably going on to vesiculation. They 
may occur in crops or simultaneously involve several regions of the 
surface of the body. They may develop after typical variola. 1 Like 
variolous Lesions, they extend at times to the mucous surfaces of the 
eyes, the mouth, and the genital regions. Occasionally they are pro- 
ductive of pruritic sensations. < Mien the course of the disease is so 
mild and the exanthem bo slight as scarcely to attract attention. Cic- 
atrices result only in places, chiefly the face, where the lesions have 
been subjected to local irritation. 

Etiology. — The disease is infectious, and if inoculable such a re- 
sult rarely is obtained. In the large majority of all cases it is a dis- 
ease of infants and children ; and though an enormous experience of 
authors is cited to the contrary, we have observed it in a few in- 
Btances in adults, and even still mere rarely in advanced years. Sec- 
ond attacks may occur, but are infrequent. The source of the disease 
is invariably an infected subject. 

Diagnosis. — The doctrine that varicella is a mitigated form of 
variola has been practically abandoned in consequence of the re- 
searches of pathologists. It is of vast importance thai the essential 
differences between the two diseases be exactly and generally recog- 
nized. 

In variola the invasion-period of relatively fixed limits, the speedy 
transformation of the lesions into minute, firm papules, their early 
appearance on the exposed parts of the face and wrists, the age of 
the patient, the thermic variations, the prodromic rashes, and the 
rapid transformation of the papules into umbilicated vesicles, arc all 
important diagnostic points. In varicella the trunk usually exhibits 
the greater number of lesions, which appear often in successive crops. 
Beside the characteristics of ihe cutaneous lesions the catarrhal symp- 
toms of measles and the sore-throat of scarlatina will point to the 
nature of these disorders. Impetigo contagiosa is to be carefully dis- 
tinguished from varicella, since the two affections occur at times side 
by side in one hospital ward, and occasionally the former succeeds the 
Latter. The lesions of impetigo contagiosa are often larger, generally 
more persistent, and the crusts bulkier than in varicella, and the 
patients rarely exhibit pyrexic symptom-. 

In those raiv instances where varicella appears in later adult life, 
an immediate differentiation from variola may be difficult or im- 
possible. Especially is this true when in such an one the varicella 
is complicated by a coincident attack of herpes zoster frontalis, an 
event which we have observed ii e case. 

Pathology. According to Onna, the varicellous process begins 
with a " reticulating liquefaction" of some of the prickle-cells of the 
■Schamberg, Phila. Med. .lour., 1902, ix., p. 442. 



VACCINIA. 437 

central and upper portion of the rete in which the first congestive 
focus is seen. The complete liquefaction of the contents of the loc- 
ulus is followed by confluence of adjacent cavities and rapid dilata- 
tion to the point of formation of a vesicle, the non-liquefied and per- 
sistent epithelium being compressed so as to form the septa, while the 
cells above produce similarly the roof-wall. The epithelial cells of 
the base undergo, on the other hand, " ballooning colliquation " (trans- 
formation of cells into hollow spheres or balloons having the form of 
peculiar giant-cells), a change affecting especially the centre of the 
pock, its lateral margins, and even at times its septa. Internally, 
these ballooned cells merge into simple cedematous epithelium with 
constricted nuclei. Careful observation of the lesions of varicella 
demonstrates that the vesicles are as distinctly divided into septa as 
are those of variola. These lesions are never monolocular. Their 
benign course is explained pathologically by their superficial position, 
by the absence of purulent infection, and by early repair with young 
epithelium. The absence of umbilication is explained by the acuity 
of the process. Bareggi, Guttmann, Pfeiffer, and others claim to 
have discovered micrococci and protozoa both in the blood-corpuscles 
and in serum obtained from subjects of the disease; but no patho- 
genic relation of these germs has been established. 

Treatment. — The management of uncomplicated cases of varicella 
is limited to the avoidance of exposure to sources of aggravation of 
the affection. Often a dusting-powder may be applied over the sur- 
face after a lotion of thin oatmeal-water. Cases complicated by the 
accidents of exposure or by the intensity of the disease are to be 
treated by the resources of general medicine according to the indica- 
tions presented. 

VACCINIA* 

(Cow-pox. Ger., Ktjhpockejst ; Fr., Vaccine.) 

The limits of this volume forbid a discussion of the interesting 
questions concerning the relations of cow-pox as it occurs spontane- 
ously in the milch cow, to human variola. A careful collation of the 
results obtained by a large number of vacciniculturists of recent days 
renders it clear that it is a matter of great difficulty to transmit variola 
from man to the heifer; that where this rare result is obtained the 
lymph derived from the lesions on the udder or the belly of the animal 
is liable to produce variola when retransmitted to man ; and that spon- 
taneous cow-pox seems fittest to furnish a lymph which is safely 
inoculable in generations to the human race. 

Of greater importance is it to note that, either by arm-to-arm vac- 
cination as was formerly extensively practised, or by the use of the 
animal virus which is now well-nigh exclusively employed, there has 
been conferred upon millions of human beings a degree of protection 
against variola the value of which is beyond estimate. In both 

1 Cf. Osier, Modern Medicine, Vol. ii., p. 316. 



ETPBBMMIA8 AND INFLAMMA TI0N8. 

Is the Lymph is originally derived from the female of the 
row. preferably daring the puerperal state, and its sources are the 
vesicular lesions of vaccinia spontaneously arising or artificially culti- 
vated about the teats, udder, and adjacent parts. The introduction 
of this lymph into the skin of the human subjecl is termed "vacci- 
nation." 

The operation of vaccination Bhould eliminate to the largest ex- 
tent the possibility of transmitting any other contagious disease than 
the one intended. With this object in view, no better instrument 
can be devised than a clean needle, one which has heen properly dis- 
infected and not previously employed for any purpose. The skin of 
the pari selected for vaccination being firsl cleansed antiseptically 
and subjected to Blighl tension by the left hand, the vaccinator should 
Bcratch or scrape off the epidermis with the needle, held in the right 
hand, by a series of parallel and crossed Btrokes, so as to make three 
or four superficial erosions three inches or more apart. Each of 
these multiples wound- should have the size of the nail of the little 
finger, and Bhould in no case bleed, but merely ooze with serum 
slightly tinged with blood. At Buch points the lymph, preferably 
extruded by air-pressure from a slender glass tube in which it has 
hermetically been sealed, is to be rubbed in -lowly and thoroughly. 

Between the third and the fourth day after a successful vaccina- 
tion of the unprotected a light-reddish, pin-head-sized maculo-papule 
rises at each inoculated point. Between the fifth and the sixth day 
it becomes transformed into a translucent, well-distended, occasion- 
ally umbilicated vesicle, which, when Bingle, may attain the size of a 
finger-nail. Springing from the multiplex abrasions described above, 
a minute papule usually forms at each point of intersection of the 
crossed lines produced by the scratching with the needle, and the sub- 
sequent vesicles coalesce, thus forming by the sixth day a compound 
lesion of rather peculiar aspect. It appears often as a small-coin- 
sized plaque, elevated to the extent of a line or more beyond the gen- 
eral level of the skin-surface, with a rim formed of numerous dis- 
crete <>!• confluent vesicles, which in either case are closely set 
together. The compound plaque seems to develop afterward as a 
single lesion, its centre being depressed. After the ninth day the 
fluid becomes opalescent, and desiccates in ;i reddish-brown crust, 
which, examined in section in a good lighl after it is completely dried, 

exhibits a smooth, homogeneous, shining appearance with a color hav- 
Ing the Bhade of amber. The ha-c of the lesion, single or compound, 
i- usually very distinctly indurated. 

Fully as important as any of the mctai phoses of this lesion is 

its rosy-red areola, in the absence of which it has been held thai there 

i- not proper protection. The areola, which endures from about the 

fifth to the tenth day. completely encircles the compound vesicle in 
the form of a halo having a diameter of several inches, the tissue it 
invade- being often Blightly tumid. When the pathological process 
in the focus of this areola is intensified, either as the resull of the irri- 



VACCINIA. 439 

tant character of the virus or from extrinsic causes (undue exertion 
of the vaccinated part), the areola may spread down the arm or over 
the thigh or leg and eventually cover a dense, brawny, and deeply 
reddened integument. Dermatitis, erysipelas, lymphangitis, aden- 
opathy, and severe grades of inflammation of the subcutaneous 
tissues may for similar reasons complicate the process, which may ter- 
minate by central sloughing, ulceration, slow repair, and the pro- 
duction of an atypical cicatrix. Ordinarily the subjective phe- 
nomena are limited to a mild or annoying itching of the vaccinated 
surface; in other cases severe burning pain, a feeling of tension, 
well-marked adenopathy of the lymphatic glands in the vicinity, and 
even sympathetic fever may be aroused. 

The acme of a successful vaccination is usually attained between 
the tenth and the fourteenth day, after which the symptoms of the 
disorder gradually subside, the crust falling, if undisturbed, in the 
course of the ensuing week. When " animal " virus is employed the 
duration of each of these stages of the disease is usually somewhat 
prolonged. 

The cicatrix, at first slightly reddened or pigmented, gradually 
assumes the dead-white appearance of scars in general. When typical 
it is slightly depressed, circular, not irregular nor deformed by 
ridges, cords, or bands, and " foveolated," exhibiting a series of peri- 
pheral pits or depressions, each of which represents the site of a 
former minute vesicle of simple type. The degree of protection is 
based in part upon the multiplicity of typical cicatrices. 1 

The complications of vaccination are due : first, to the character of 
the virus employed ; second, to the character of the soil in which it is 
implanted ; and, third, to the external accidents to which the vaccine- 
lesion is subjected. Respecting the first of these sources, there are 
few contagious diseases beside syphilis which may be transmitted by 
vaccination. When this accident occurs it may be due either to 
syphilis in the vaccinifer or to the use of instruments soiled with in- 
fectious secretions. The lymph from a typical vaccine-vesicle upon 
the skin of an intensely syphilitic vaccinifer will necessarily transmit 
syphilis if accidentally it be commingled with either blood or the 
products of inflammation at the base of the pock. The stage and 
intensity of the disease in the vaccinifer are elements which can- 
not be ignored in forecasting the issue. The vaccine-lesion may 
complete its career during the incubative period of the initial sclerosis, 
the existence of which at the site of vaccination is commonly declared 
later by induration, ulceration, pigmentation, and axillary adenop- 
athy. The occurrence of a generalized syphiloderm before the chan- 
cre of vaccination is completely healed may be the first symptom to 
arouse suspicion. The popular impression regarding the frequency 
of this accident is erroneous. The rarest of all modes of transmission 
of syphilis is that by vaccination. In all such cases the possibility 

1 Welch-Schamberg, ' ' The Characteristics of Genuine Vaccinia, ' ' St. Louis Med. 
and Surg. Jour., 1902, lxxxii., p. 199. 



44»> HTPSBA9MIAS AND INFLAMMATIONS. 

that the- syphilis may be hereditary and its symptoms simply coinci- 
dent in point of time with those of vaccinia, should not be forgotten. 
It is possible that lepra and tuberculosis may thus be transmitted, 
but such accidents are exceedingly rare. 

eedingly dangerous is that vaccine-virus, however good its 
early character, in which decomposition or putrefactive changes have 
occurred after exposure in a liquid form to the action of heat and 
the atmosphere. Vaccination with lymph thus changed has rapidly 
been followed by fatal results, in consequence of the supervention 
of pyaemia, septicaemia, or gangrene. 

Complications of vaccinia, due to the character or predisposition 
of the tissues in which the virus is introduced by the vaccinator, are 
usually ascribed by the ignorant or the prejudiced to the causes just 
considered. Post hoc ergo propter hue i> the sole logic of the unin- 
formed. In this way each of a series of maladies has been ascribed 
to "impurities" and ''humors'' introduced by vaccination. The 
arguments used in support of these assumptions are without basis 
in the most of cases. The cutaneous Bymptoms which may be awak- 
ened by vaccination arc numerous. It will l»e remembered that the 
contents of the typical vaccine-vesicle are auto-inoculable, and that 
thus the scratching by young patients may produce an abundant crop 
of typical or torn vesicles upon the arms, legs, thighs, hands, and fin- 
gers. But vaccination may awaken in the patient, as explained 
above, a latent syphilis, as also a list of cutai us disorders not con- 
tagious in character. Thus, an erythema (roseola vaccinia, vaccinola, 
etc.), eczema in many of its forms, and other exudative processes may 
be aroused first in the integument by the turbulence of a successful 
vaccination. 

These rashes may become generalized, 1 and may even assume a 
formidable appearance. They may appeal- at any time from the 
second to the fourteenth day after vaccination. A scarlatiniform 
rash, diffused or in patches, is described by some authors as occurring 
in this way, accompanied by mild fever, and resembling German 
measles. Similarly generalized eruptions, resembling erythema mul- 
tiforme, erythema searlat iniforme, eczema, psoriasis, pemphigus, urti- 
caria, impetigo contagiosa, varicella, and other cutaneous disorders, 
may appeal' for the first time within the limits named above. They 
usually disappear within a brief time after the vaccine-vesicle has 
completed its involution, and may be followed by slight desquamation 
or pigmentation. Very rarely vaccinia is followed by erysipelas, 
by purpuric symptoms, and by the development of lupus-nodules at 
the site of inoculat ion. 

Vaccinia Hemorrhagica.- This is a term descriptive of a complica- 
tion of either th<' vesicle of vaccinia or of lesions surrounding the 
latter. In these cases there is hemorrhage into the vaccine-vesicle 

1 Barton, L. t Archiv, 1908, Ixv.. p. 889; Piffard, J. C. D., 1899, xvii., p. 467; 
Morrow, B. J. D., L901, xiii., p. 188; Freeman, Lbi<l.. mm', xiv., p. 186; Stelwagon, 
.1. A. M. A.. L902, max., p, L291; Towle, Boston Med. and Surg. Jour.. L908, 
cxlvii., p. 869; Beidingsfeld, J. C. D., 1902, rx., p. 67. 



VACCINIA. 441 

or the development of petechia in its neighborhood. As a result of 
uncleanliness, not only may erysipelas be communicated as noted 
above, but septic infection, gangrene, tetanus, and other affections 
may originate at the site of a vaccine-vesicle. 

Anomalies of the vaccine-vesicle occasionally are noted as to shape, 
career, and resulting cicatrix, which are difficult to explain. Thus, 
the papulo-vesicle may not exhibit an umbilicated centre, or may com- 
plete its course within unusually short limits ; or a harmless ulceration 
may progress beneath its crust, requiring a week, or even more, for 
complete cicatrization. The so-called " raspberry-sore " results from 
coalescence of small papules, so as to form a pigmented tubercle. 
The scars resulting from many of these irregular and non-protective 
results of vaccination usually form atypical cicatrices, being, in one 
case, small palm-sized, deforming, corded, and representative of large 
tissue-loss; and, in another case, irregular and inconspicuous. 

Lastly, the complications of vaccinia due to external accidents of 
the lesion are usually inflammatory in character. The excessive use 
of the vaccinated arm in labor and of the vaccinated leg in walking, 
standing, and other exertion, may induce, as indicated above, every 
grade of dermatitis and even ulcerative changes in the site of the 
inoculation, as a result of the intensity of the process. For these acci- 
dents rest is essential, with the free use of a dusting-powder over the 
inflamed surface. In exaggerated cases lotions of lead-water and 
opium may be employed. These conditions usually are relieved 
without difficulty as soon as the part is put to rest. The atypical 
scar which results seems to be in such cases as protective as others, 
if only the accident have occurred to a typically progressing lesion 
with distinctly perfect areola. Vaccine-cicatrices are to be distin- 
guished in anomalous situations from maculae atrophica, the scars 
of syphilis, and other scar-leaving disorders. 

Bullous Dermatitis following Vaccination, at times with fatal results, 
occurring both in infants and adults, is a disorder of special impor- 
tance. Cases of this type have been recorded by Bowen, 1 Howe, 2 and 
others. K"one of those reported by Bowen proved fatal. The bullae 
appeared on the trunk in adults, though in children this region was 
spared; and were isolated or confluent, of, different dimensions from 
that of a split pea to the size of small coin, often associated with 
oedema, purulent secretion from the parts invaded, and the formation 
of blackish crusts, the lesions in certain cases sparsely, in yet others 
abundantly distributed over the entire body surface. About five 
weeks after vaccination the exanthem appeared in the dangerous cases, 
those resulting fatally suffering from the usual complications of ex- 
haustive disease. Some of the patients were unmistakable subjects 
of chronic alcoholism. The connection between the vaccination and 
the subsequent eruption is not definitely established. We have had 
two cases in children and two in adults. All eventually recovered. 

1 J. C. D., 1901, xix., p. 401. 

2 Ibid., June, 1903, xxi., p. 254. 



442 HYPEREMIAS AND INFLAMMATIONS. 

Generalized Vaccinia. — Generalized vaccinia (vaccinal eruptive 
fever) usually results from a non-cutaneous introduction of vaccine 
virus; and i- characterized by the production of vesicles of vaccinia 
in crops, which resemble Btrongly the lesions of variola. Supernum- 
ii-v vesicles form, at times on the mucous surfaces of the mouth, with 
febrile symptoms and subsidence of the eruption in about three weeks. 

Pathology. — In the vaccine vesicle according to Onna, the epi- 
ilieliuin undergoes ballooning BS in variola and varicella, hut in the 
first-named affection the two forms of degeneration, "reticulating 
colliquation " and "ballooning," are peculiarly commingled. The 
greater prominence of the ballooning may be due in pan to the juve- 
nile character of even the oldest Cells. The existence of an inocula- 
tion-WOlind has a marked influence on the microscopical picture, the 
resulting fissure being filled with blood-disks inside the horny layer, 
which is somewhat thickened. In vaccinia, as in the two maladies 
which pathologically it most resembles in its lesions, the formation 
of the vesicle is by chambers, the septa consisting of collections of 
cells (granular and others) which seem to he the remains of sweat- 
pores. 

.Micrococci have been recognized by Cohn in vaccine-lymph. 
These have been named " micrococci vaccina?," but their relation to 
similar organisms discovered in the Mood and tissues of variolous 
patients has not been determined. Wolff 1 claims to have cultivated 
these organisms through fifteen generations. Strauss demonstrated 
their existence in the vaccinal pustules of the ealf. 

Lipp, of Gratz, reported to the International Medical Congress, 
in London, that he had recognized great similarity, if not identity, 
between the micrococci of vaccinia and those of variola that he had 
cultivated to the second generation, but had then been unsuccessful 
in producing inoculation-effects. These organisms were always ar- 
ranged in groups of four or multiples of four. 

Steinhaus reports that Tuna's ballooning and reticular degenera- 
tions play no part in the formation of the pock in animals. The 
process is, instead, Ziegler's dropsical degeneration with typical 
mitoses, but without division of the cell-nucleus. 

Treatment.- — The management, of the severer types of vaccinia and 
of the complications of the disease is to be conducted in accordance 
with the principles of treatment described in connection with derma- 
titis Venenata and acute eczema. 



THE FOURTH DISEASE (DUKES DISEASE). 

Duke described a disease which he believed belonged to the acute 
Exanthemata Group. The period of incubation was nine to twenty- 
one days, as in German measles. Prodromes were absent excepting 
malaise and Blighl SOre throat in the early onset of the disease. The 

rash appeared rapidly and spread over the entire body in a few hours. 
' Merlin, klin. WYlms.-lirit .. January 22. 1883. 



BOCKY MOUNTAIN SPOTTED FEVER. 443 

The color was brighter than in scarlet fever. There was some glandu- 
lar enlargement and but little temperature (101° F.). There were 
no sequela?. This disease has not been accepted as a clinical entity. 

ROCKY MOUNTAIN SPOTTED FEVER. 1 

(Tick Fever of the Rocky Mountains, Piroplasmosis Hominis, 
Black Fever, Blue Disease, Sheep Camp Fever.) 

The above titles designate an acute infectious disease accompanied 
by mild or severe constitutional symptoms with a cutaneous exan- 
them having multiform characteristics. 

It was first described by Wood in 1896 and in 1899 by Maxey, 
since which time many observers have made reports concerning its 
■clinical, pathological, and bacteriological aspects ; unrecorded cases 
have been noted in some of the regions where it is now prevalent 
since 1873. The disease is found chiefly in the Rocky Mountains in 
the states of Montana, Idaho, Utah, and Oregon. 

Symptoms. — The disease is ushered in, as are many infectious 
processes, with chill or chilly sensations, malaise, followed by a rapid 
rise of temperature, general soreness over the entire body especially 
severe in the back and legs. Headache is common and epistaxis is 
frequently associated and may be severe during the second week. 
The tongue is coated and constipation is the rule. The temperature 
rises suddenly after the onset and remains more or less high from 
100° to 105° or 106° F., for ten to twelve days when in mild cases it 
begins to decline, reaching the normal in the third week. The erup- 
tion occurs in from three to five days after the onset on the wrists, 
ankles, and back, and gradually spreads over the limbs and trunk 
including the palms and soles in some cases. Late in the disease it 
may involve the mucous membrane of the mouth and throat. It ap- 
pears in crops like a purpuric toxic erythema, the first lesions being 
pinkish or reddish macules which later become darker in color and 
finally hemorrhagic. In severe cases intense hemorrhagic areas may 
■occupy the entire cutaneous surface. Diffused over the surface there 
is usually an icteric discoloration in addition to the lesions described. 
The eruption terminates with desquamation during convalescence. 
Desquamation is most marked on the hands, feet, and face. 

With the rise of temperature the pulse rate increases from 110 to 
140 in average cases and the respirations range around 36 per minute. 

1 Bibliography : Wood, Kept., Surg. Gen. Army, 1896, pp. 60-65. Maxey, 
1899, Medical Sentinel, vii., pp. 433-438. Wilson and Chowning, J. A. M. A., 
1902, xxxix., pp. 131-138 ; and Journ. Infect. Dis., 1904, i., pp. 31-57. Anderson, 
Bulletin 14, Hygienic Laboratory of United States Public Health and Marine 
Hospital Service, 1903. Stiles, ibid., No. 20, 1905. Eicketts, J. A. M. A., 
1906, xlvii., pp. 33-36, p. 358, and pp. 1067-1069; Journ. Infect. Dis., 1907, iv., 
pp. 141-153. King, 1906, Public Eeports, July 27th. Idaho, State Medical Asso- 
ciation, 1908; J. A. M. A., li., Nov. 21st; Symposium on Eocky Mountain 
Spotted (Tick) Fever, papers and discussions by Stewart and Smith, Maxey, 
Eicketts, Tuttle, Numbers, McCalla, Taylor, Kleinman. Osier's Modern Medicine, 
"Vol. iii., pp. 535-540. 



444 EYPERMMIA& AND INFLAMMATIONS. 

A moderate bronchitis i- common and pneumonia is a frequent 
complication. Nausea ;m<l vomiting may occur during the second 
week and may be intense in severe cases. The spleen is enlarged 
and tender and the liver shows some increase in size. Hemorrhages 
may occur from the nose, mouth, stomach, and bowels, and hemor- 
rhagic effusion into the joints has been recorded. The urine is di- 
minished in amount and high col.. re. 1. and may show traces of albu- 
min and some easts. The nervous manifestations include restless- 
ness, irritability, pain, hyperesthesia, and in severe cases delirium 
and Btupor, while coma usually precedes death. The blood showa 
a diminution of red cells and haemoglobin. The leucocytes are either 
normal in number or moderately increase.] ( S000 to 14000) with 
an increased percentage of the Large mononeuclears. 

Pneumonia, and gangrene of the skin of the terminal extremities, 
scrotum, and penis occur as complications. 

Etiology and Pathology. — The disease occur- usually during the 
spring months from March to duly — May and June furnish the 
major portion of cases. It attacks both sex.- and may occur at any 
age. The infective agent is inoculated in most instances by the bite 
of a tick (Dermacentor Occidentalis). Several hundred cases occur 
annually and the virulence varies in different years. In Montana 
a more severe type of the disease is usually noted. It occurs com- 
monly among people who are closely associated with sheep herds in 
the mountains. Ricketts and others have reproduced the disease 
in animals (monkeys, rabbits, and guinea-pigs). He also has dem- 
onstrated the susceptibility of several animals indigenous in that local- 
ity to the disease (gopher, grounddiog, chipmunk, rock squirrel, and 
mountain rat). 

The various theories concerning the life history of the micro- 
organism | as yel not isolated ) with its numerous host- are interesting 
but cannot be detailed here. 

I lie chief pathological findings, posl-mortcm, have been noted 
in the skin, spleen, liver, pancreas, and kidneys. 

Treatment. — No specific medication is known and opinion is 
divided concerning the value of quinine. The general care of the 
patient with symptomatic treatment and good nursing give best 
results. 

Prognosis.- The average mortality ranges from four to ten per 

Cent. .it times a much higher rate has been recorded. Death usu- 
ally occurs during the second week of the disease. 



CLASS II. 
HEMORRHAGES 



PURPURA.' 

(Gr., nufxpvptog, purple.) 



Purpura may be a symptom or a disease — that is, it is sympto- 
matic or idiopathic. It may be defined as a condition in which there 
occur spontaneous hemorrhages in and beneath the skin and mucous 
membranes. The disease, purpura, differs from hemophilia in that 
it is acquired and, as a rule, transitory ; and from scurvy by its non- 
epidemic and non-endemic nature. 

Classification. — A grouping of the secondary purpuras is not diffi- 
cult — authorities agreeing more or less generally on the morbid states 
in which hemorrhages occur as a symptom. A satisfactory classifi- 
cation, however, of the idiopathic variety cannot be made until the 
pathology of the condition is better understood. It can be urged, 
nevertheless, with good reason that all purpuras are not symptomatic 
— that is, there is a true idiopathic purpura. 

Secondary Purpura. — Hemorrhages may occur in the course of any 
acute infectious disease. They are more common in variola than 
in any of the other exanthemata. There are hemorrhagic forms 
also of measles and scarlet fever. In the diagnosis of ulcerative 
endocarditis, petechia are of great significance. Epidemic cerebro- 
spinal meningitis derives its name, " spotted fever " from the fre- 
quent occurrence of a hemorrhagic eruption. Purpura may take the 
place of rose-spots in typhoid fever. In typhus fever the eruption is 
always purpuric. Pyemia and septicemia may show very abundant 
ecchymosis. 

Toxic Purpura.. — A long list of drugs may cause the appearance of 
purpura. The iodids are especially prone to lead to hemorrhages, 
idiosyncrasy being a prime factor. In addition to the cutaneous 
manifestations, there may be marked febrile disturbances. Copaiba, 
quinine, ergot, mercury, chloral, salicylic acid, arsenic, and bella- 
donna may also lead to a purpuric rash. Snake venom is a well 
known etiologic factor made use of in the production of experimental 
purpuras. 

Cachectic Purpura. — This is the type seen most commonly in hos- 
pital practice. Thus in chronic nephritis and heart disease, the 

1 The author is indebted for much tff the recent material embodied in this 
article to the monograph by Joseph H. Pratt found in Osier's "Modern Medi- 
cine," Vol. IV., pp. 681-716. In these pages idiopathic purpura has a distinct 
place founded on new and painstaking research. 

445 



446 SBM0BBHAGE8. 

development of hemorrhages especially on the legs, is of comparatively 
frequent occurrence. In the anemias — primary and secondary — 
in the leukemia-, in Eodgkin's disease, tuberculosis, carcinoma, 
chronic alcoholism in the senile state, and other disturbances of nu- 
trition, hemorrhages are not unusual Bymptoms. 

Nervous Purpura,— Purpura may occur both in the organic and 
functional diseases of the nervous system. In tabes, following the 
Lightning pains over the area where the latter have been most intense; 
in acute transverse myelitis; in insular sclerosis; in hemiplegia on the 
affected side; and in the neuralgias, hemorrhages sometimes appear. 

Among the causative factors, functional in nature, are fright, hys- 
teria, the menstrual state, and stigmatization in which bleeding- 
point- appear upon the unbroken skin. 

Mechanical Purpura. — Examples of this appear often after the 
paroxysms of COUgh in pertussis and after the seizure in epilepsy. 

The application of a tight bandage may lead to a hemorrhagic 
rash. A mechanical influence also is effective, probably most com- 
monly in the development of pupura on the lower extremities. 

Idiopathic Purpura. — In the tables shown by Pratt there are 1!»4 
cases of primary to 258 cases of secondary purpura. The disease is 
most common among males in the second decade. Season and hered- 
ity play a part in the etiology. (See Ceevical Varieties, p. 447.) 

Pathogenesis. — The question of pathogenesis is still unsolved. 
Microorganisms have not been found ill blood cultures. The condi- 
tion of the blood-vessels is important but whether the changes are pri- 
mary or secondary is not known. Focal degeneration, thrombosis, 
and a solution of the endothelial cells have all been described as causa- 
tive factors. 

Two constant findings seem to be present in the blood — a diminu- 
tion of the blood-platelets and disinclination of the blood-clots to 
contract. 

General Symptomatology.— The lesions of purpura have the fol- 
lowing characteristics in common : They all are due to escape of blood 
into the tissues; they do not fade under pressure; they usually appear 
suddenly; a1 first they are of a bright- or deep-red color, which in a 
tew hours or days changes to the duller and darker shades of red, 
purple, and brown, which in turn, beginning at the centre, slowly 
fade through various shades of brown, green, and yellow to the nor- 
mal color of the skin. On the lower extremities the pigmentation 
sometimes persists tor years. According to their shape, size, and ar- 
rangement, the Lesions of purpura are designated as petechia which 
are pin-point- to small coin-sized, usually well-defined macules, some- 
times situated about the hair-follicles; ecchymoses, which are like 
petechias, except that they are Larger and more irregular in shape and 

in distribution, sometimes covering the entire surface of a limb; 

and vibice8, which are linear ami band-like arrangements of ecchy- 

moses. Occasionally the hemorrhage takes the form of bulla 1 (bulla 
hcemorrhagica) , or of nut- to egg-sized, and even larger, tumors 



PLATE XVII 




Purpura Due to CopaibJ 

(From a painting.) 



CLINICAL VARIETIES OF IDIOPATHIC PURPURA. 447 

(eccliymomata) . At times purpura is seen in the form of minute 
papules. In addition to the clinical forms above described, purpura 
may appear as a complication and modification of the various lesions 
of erythema multiforme, urticaria, and other cutaneous diseases. 
The disorder may be recurrent or even persistent. Osier 1 reports a 
case of purpuric erythema, of eight years' duration, associated with 
pigmentation of the skin and enlargement of the liver and spleen. 

Diagnosis. — The diagnosis of the symptomatic purpuras rests 
upon the discovery of the etiology. The idiopathic variety is recog- 
nized by the absence of any tangible causative factor ; while the dif- 
ferent types are distinguished by the features mentioned in the follow- 
ing paragraphs. 

In addition to the distinctive signs of scurvy and hemophilia, the 
epidemic nature of the former, and the congenital or hereditary factor 
in the latter, should make a diagnosis easy. 

Treatment. — Attention, in the symptomatic form, should be given 
to the underlying condition. Rest and a light nourishing diet are in- 
dicated in all cases. Foods rich in iron and fresh fruits are of value. 
Warm baths are to be recommended during the course of the disease 
and in convalescence. Among useful drugs are Fowler's solution in 
increasing doses, aromatic sulphuric acid, calcium salts for a few days 
at a time, and oil of turpentine. The salicylates and the coal tar 
products are, as a rule, of little value. Locally, in bleeding from the 
mouth or nose, irrigation with 1 to 1000 adrenalin or two per cent, 
gelatin is useful. Iron is indicated during convalescence. 

Prognosis. — In the secondary purpuras, the outlook depends upon 
the gravity of the causative factor. 

Of the idiopathic types, simple purpura, with and without arth- 
ritis, is nearly always of favorable prognosis ; purpura f ulminans and 
Henoch's purpura (especially associated with nephritis) not infre- 
quently terminate fatally. Cerebral hemorrhage is a common cause 
of death. 

CLINICAL VARIETIES OF IDIOPATHIC PURPURA. 

Purpura Simplex. — This type is characterized by the appearance, 
in- crops, of a purpuric eruption. The form is usually petechial and 
the site of election the legs. The rash is ordinarily the only symptom, 
though slight fever, joint pains, and gastro-intestinal disturbances 
may be present. The average duration is from two to six weeks, 
though the case may become chronic and last a year or more. 

Purpura Rheumatica. — Simple purpura with arthritic manifesta- 
tions. 

This variety of purpura, which has a striking analogy to erythema 
multiforme, is probably an exaggerated form of some of the conditions 
recognized under that title. It is preceded as a rule by febrile or 
other premonitory symptoms associated with arthritic pains, especially 
of the knees and ankles, which may become swollen or be affected with 

1 J. C. D., 1903, xxi., p. 297. 



1 Lfl HBM0RBHAQ1 \ 

a hydrarthrosis. In a few 'lavs petechial to ecchymotic, light-red to 
dark-purplish maculations appear upon the extremities, the trunk, or 
tire surface of the body, uot fading under pressure, and usually 
with coincident relief of the arthritic pain. The subjective sensations 
are ordinarily trivial. In a fortnight the eruption may subside, its 
color undergoing the usual variations from greenish to orange and 
Light yellow; but relapses are common in the course of weeks, with 
recrudescence of the fever, return of rheumatoid symptoms, and pro- 
asthenia. The purpuric spot.- sometimes make their appear- 
ance regularly in the afternoon or evening, sometimes daily and often 
with several days' interval, accompanied by pain, stiffness, and 
swelling of joints. The arthritic symptoms are extremely variable 
and may be Blight or Bevere. While most common in the knees and 
ankles, they may appear in any joints of the body. Associated with 
the purpura and the arthritic symptoms there are often mild or severe 
gastro-intestinal disturbance a. 

There are thus, in the majority of cases, three groups of symptoms, 
the cutaneous, the arthritic, and the gastro-intestinal. It is rare, how- 
ever, for these symptoms to be equally severe in any one case, one 
or two of the groups being usually but slightly or not at all apparent. 
Frequently one group follows another. Thus, the arthritic pains 
may subside before the appearance of the purpura, or the reverse may 
be true. Throat-lesions, acute circumscribed oedema, 1 and urticaria 
are often seen with one or more of the groups of symptoms above 
described. The intimate relation of purpura rheumatica to erythema 
multiforme is discussed in the pages devoted to the latter disorder. 
Cases are described in which there was coincidence of purpura rheu- 
matica with renal hemorrhage, albuminuria, and gangrene of the 
soft palate. Cases are also on record in which there were cardiac in- 
volvement and grave disorders of other viscera. 

The disease occurs in both Boxes, though more often in young men. 
and is to a certain extent influenced by the changes of climate and 
season. Its diagnosis, in consequence of its marked characteristics, 
coincidence of petechia? and ecchymosea with rheumatoid pains, is ef- 
fected readily. Duhring calls attention to the danger of confound- 
ing the disease with the macular Byphiloderm, the lesions of which, 
however, when relatively recent, fade under pressure. 

Purpura Hemorrhagica (Morbus Maculosus Werlhoffii). — This 
type is characterized by the association of severe purpura with hemor- 
rhage- from the mucous membranes. The disorder is usually ushered 
in with phenomena of a febrile character, accompanied by symptoms 
of genera] depression. Subsequently ecchymoses appear upon the 
extremities and the trunk, both spontaneously and at points at which 
the integumenl has specially been subjected to pressure and friction. 
Often petechia? appear simultaneously upon the nasal, laryngeal, buc- 
cal, and other mucous Burfaces, which may also be the seat of exhaust- 
ing hemorrhages, resulting rarely in fatal collapse. A symptomatic 

l Cf. Bowen, J. C. D., 1892, x., p. I'.t | references to literature). 



CLINICAL VARIETIES OF IDIOPATHIC PURPURA. 449 

fever is usually awakened. The disease occurs most commonly in 
delicate young females, but may attack robust adults of either sex. 
Purpura hemorrhagica is slow in its course, but, as a rule, terminates 
favorably after the lapse of several months. In some instances the 
general symptoms are those of typhoid fever; and hemorrhage from 
the mucous surfaces, including those of the stomach and intestines, 
may be severe. In yet severer cases, to which the name Purpura 
fulminans is applied, the symptoms are those of septicaemia or of 
other acute and severe infection. In these cases extensive internal 
hemorrhage may be followed by death. Little 1 reports a series of 
cases in infants with a rapidly fatal termination and associated with 
hemorrhage into the suprarenal capsules. Many of the severer cases 
of hemorrhagic purpura undoubtedly are due to infections the exact 
nature of which is not understood. 

The lesions commonly appear first on the upper extremities, then 
over the trunk, and finally over the lower extremities. They are 
usually dark red or purplish in hue, varying in size from that of a 
pin-head to that of a bean, but they may be of the size of the palm. 

Henoch's Purpura. — This type is seen chiefly in children and, 
according to Osier, has the following characteristics : (a) Relapses or 
recurrences often extending over several years. (&) Cutaneous 
lesions which may be simple purpura, purpura urticans, urticaria, 
angioneurotic edema, and erythema in all its multiform varieties ; in 
successive attacks, the skin lesions may vary greatly, (c) Gastro- 
intestinal crises, pain, vomiting and diarrhcea. (d) Joint pains or 
swelling, often trifling, (e) Hemorrhages from the mucous mem- 
branes. (/) Enlargement of the spleen, (g) Nephritis which is the 
most serious feature and the most frequent cause of death. 
1 B. J. ~D., 1901, xiii., p. 445 (with bibliography). 



29 



CLASS III. 
HYPERTROPHIES. 



KERATOSIS. 

(Gr., nepag, a horn.) 



General considerations respecting the several disorders commonly 
included under the titles Congenital and Acquired Keratoses, Hyper- 
keratoses, and Dyskeratoses : 

Keratosis was first applied by Lebert to hypertrophic lesions of 
the epidermis. It has since been made to include changes in both the 
epidermis and the corium, and it is employed by some authors in a 
generic sense to embrace a number of both localized and general hy- 
pertrophies of these portions of the skin. 

The disorders springing from abnormal development of the horny 
layer of the skin, and its associated morbid phenomena even though 
first observed in later life are often of congenital origin. In some 
instances the extreme picture can be recognized soon after birth; in 
other cases the skin of the new-born infant to the untrained eye 
scarcely exhibits unusual symptoms ; in its further development, 
however, the child in the course of months or years may exhibit one 
or more of the several diseases and deformities suggested by the 
titles named above — in mild or severe expression. 

Reviewing this series of congenital keratoses, it is to be admitted 
that in the past enormous confusion has clouded the recognition of 
the character of the individual disorders and their mutual relations. 
Lenglet, 1 recognizing the difficulty of establishing the pathogeny of 
these conditions, either on an anatomical basis or on the ground of 
the agencies which influence the skin after birth, has established a 
classification which at least attempts to solve the problems presented. 
It is founded on two essential facts : the first is that the embryonic 
epiderm is constituted of two distinct layers, the most superficial 
representing the epitrichial layer found in the lower animals which 
if it adheres too firmly to the deeper layer and be not normally shed, 
results in (a) the advent of the infant into the world completely en- 
cased in an envelope which overlies the deeper cutaneous structures, 
or (6) the epitrichial layer surviving, profoundly influences the un- 
derlying integument and in this way lays the foundation for further 
changes. The second fact of importance is the change in evolution 
produced by many agencies obscure in operation, which profoundly 
influence the deeper layer. Hence result the clinical forms in which 

1 Annates, 1904, s. 4, iv., p. 369. 
451 



452 HYPEBTBOPHIBB. 

there is either absence of or an abnormal production of the skin ap- 
pendag 

The list of disorders directly or indirectly originating from these 
foetal layers are classified as follows: 

Anomalies of development of the appendages of the skin and its 
allied structures originating from the same germinal source (glands 
of the -kin. body-hairs and those of the hairy scalp, nails, teeth). 
Under this title arc to lie classed the cases in which there is practi- 
cally absolute and generalized failure of production of these acces- 
sories of the skin including its glands, and also those in which these 
are produced in incomplete development. I'nder the one title are 
included cases of complete alopecia with absence of sweat and seba- 
ceous glands; and under the Other are the associated conditions, mon- 
ilethrix, keratosis pilaris, ichthyosic, keratodermic, and parichthy- 
osic, with lesions of the nails, epidermolysis bullosa, and ichthyosiform 
erythrodermia. 

In a subdivision are classed those in which though the papilla? 
of the corium exist, they are wholly inactive; under this head Lenglet 
classes, first, persistence (if the lanugo after birth (producing the hy- 
potrichosis lanuginosa, of Bonnet; the primitive trichostasis, of 
Unn'a). 

Alter the fall of the lanugo, the hairs are replaced by abnormal 
filaments (monilethrix) or there is no growth. 

The more complicated processes which follow the conditions 
named above, include the palmar and plantar keratodermias of con- 
genital origin, the common forms of ichthyosis, and the foetal form 
(so-called " Harlequin foetus"). 

1 Jnder the title " lamellar exfoliation of the skin of the new-born " 
are included those cases in which the infants at birth have a dry, 
shiny, yellowish-brown skin looking as though it had been varnished 
with collodion. The ichthyosiform congenital erythrodermia, of 
Brocq, include- those cases in which over the lace and over the folds 
of the body, accompanied sometimes by bullous lesions and also by 
palmar and plantar keratosis, there is frequently an exaggerated 
growth of the hairs and nails, palmar hyperidrosis, alopecia, atrophy 
of the skin, and dilatation of the orifices of the sebaceous glands. 

Congenital bullous lesions arc often associated with palmar and 
plantar keratoses due, as Lenglel thinks, to the special friability of 
the inter-cellular spines. In these cases the slightest friction and 
pressure upon the keratosic skin suffice to induce the appearance of 
blebs. In many cases the Mebs are hemorrhagic; they are often 
accompanied by hyperidrosis; there is Prequenl pigmentation of the 
skin in the neighbor! I. 

Briefly, the congenital dyskeratoses thus outlined are: lamellar 
desquamation of the skin of die new-born; festal ichthyosis; the ich- 
thyosic congenital erythrodermias ; palmar and plantar keratoder- 
mias with their associated symptoms ; the circumscribed or generalized 
symptoms of cutaneous atrophy; the various morbid conditions pre- 



KERATOSIS PILARIS. 453 

ceding, complicated by bullous lesions ; lastly, the ordinary forms of 
ichthyosis. 

KERATOSIS PILARIS. 

(Lichen Pilaris, Pityriasis Pilaris.) 

Symptoms. — This condition may be a mere temporary functional 
disturbance of the skin, awakening no subjective sensation, inappreci- 
able by the patient and apparent only to the careful observer, or it 
may constitute a disease. Its symptoms are the occurrence of pin- 
head sized, pointed elevations of the skin-surface that may be de- 
scribed as papules, though strictly speaking, they are not such, but are 
constituted by an accumulation of horny epithelia and a small 
quantity of inspissated sebum about the lanugo-hairs of the ex- 
tensor surfaces of the extremities and trunk. These aggregations 
of material are usually of a dirty-whitish or grayish hue, and are 
pierced by a lanugo-hair implanted in the follicle about which the 
abnormal condition exists. Occasionally, however, the hairs are 
of the finer and shorter kind, and are often coiled in or other- 
wise covered by the little heaps of epithelial debris. The skin of 
the individual thus affected is generally harsh, squamous, and dry 
to the touch, suggesting that it has been long unwashed. The 
color of the quasi-papules difFers also with the complexion of the in- 
dividual; at times the papules have a distinctly reddish tinge, and 
they are often surmounted by a scale. 

Keratosis of this type can scarcely be described as a morbid state. 
Those who seek treatment for it are readily divided into two 
classes : first, comely young women desiring to exhibit bare arms in 
evening toilet; second, young men suffering from the delusion that 
they are victims of a " disease of the blood " or of syphilis. Viewed 
as a whole, the subjects of the best types of this so-called "disease" 
are men and women of exceeding vigor, with firm, well-developed 
muscles and shapely limbs. 

Keratosis pilaris is common in skins long uncleansed by ablution,, 
and this condition can thus be produced artificially. In some individ- 
uals it persists for long periods of time, and awakens no concern. In 
others, especially in children, it may become the source of pruritus, 
and each lichenoid papule may then be transformed into an urticarial 
wheal, with distinct and sometimes very annoying pricking and ting- 
ling sensations, the trouble often relieved by a bath in warm water 
with soap. In other individuals, especially in adults, an exaggerated 
form of the disease can be recognized, the skin presenting a roughness 
to the touch suggestive of the surface of a nutmeg-grater, and exhibit- 
ing numerous fine, conical, grayish, horn-tipped filaments, which has 
been regarded as a form of ichthyosis. In the latter case there is 
doubtless a true hypertrophy of the epidermis. In the former case 
there is scarcely more than a mechanical accumulation of effete or- 
ganic material. The malady, simple though it be in character at the 



4o4 HYPERTROPHIES. 

may become the first stage of a series of chronic cutaneous dis- 
orders. Tilbury Fox has reported four cases in which the disease was 
well marked, under the title of Cacotrophia FollicvXorum, this name 
being employed to designate its peculiarities as to wide distribution 
over the body, ita implication of the deeper portion of the follicles, 
and its congenital history. In these cases the reddish tint of the 
Lesions is Bhown distinctly. 

Broeq 1 describes a whin- variety, the nneolored circumpilary pap- 
ule- being scattered over the arms, forearms, legs, and thighs, usually 
on the outer faces of the extremities; and three inflammatory types: 
(a) a mild form, in which reddish papules are disseminated among 
those of the •' white" class; (b) a form of medium intensity, in which 
the papules are generally rosy-red in hue; (c) an intense form in 
which well-marked lesions occur over the surface of the chest, the 
lumbar and pubic regions, ami the folds of the larger articulations. 

Keratosis pilaris on the face, as described by French writers, is 
characterized by exceedingly minute, usually conical, occasionally 
obtuse papules (each pierced by a line hair) that develop over the 
brow, about the eyebrows, over the cheek-, ami the infra-maxillary 
region. 

Etiology.- Puberty and uncleanliness have been assigned as 
causes of the disorder; both conditions may in some patients be in- 
directly effective. In certain individuals the condition seems to fol- 
low a prolonged course of arsenic. The disease is seen frequently in 
persons having peculiarly thick, coarse, usually dark-colored skins, 
and also possessing marked muscular vigor and unusual development 
of most of the other bodily tissues. Tn brief, the disorder seems t<> 
be due often to marked inherited predisposition in persons of vigorous 
constitution. The varieties of keratosis pilaris seen in cachectic hos- 
pital-patients, and in persons who have aggravated the disease by 
inducing a medicamentous rash upon the person, belong to a dif- 
ferent category. Patients in the two classes last named may be so 
perfectly relieved that there is n<> predisposition to a return of the 
disorder, a relief not always to be secured by the others. 

Pathology.- The papules are produced by a hyperkeratosis about 

the orifices Of the pilo-SebaceOUS follicles. hi some cases the result 
is an irritation which produces a mild degree of chronic inflamma- 
tion of the periglandular tissue. Giovannini 2 found, in twenty-live 
cases, thai inflammation was not constant, but in some instances was 
a marked feature. lie found that the follicular orifices were much 
widened and deepened, and filled with a horny plug in which there 
were coiled often one or more line hairs. The hyperkeratosis in- 
volved not only the follicle, but also the epidermis about it. There 
was more or less atrophy of the outer root-sheath of the sebaceous 
glands and of the erectores pilorum. In a few instances the entire 

'Annates, L890, s. iii., i.. pp. 25, 97, and 222 (an extensive review of the sub- 
ject, with bibliography). 

»Lo Bperimentale, 1805, p. 662; abstr. In B. J. D., 1896, viii., p. 151; and 
An-hiv, 1902, Ixiii.. p. 168, will, bibliography. 



KERATOSIS PILARIS. 455 

follicle, including the hair-papilla, was destroyed. Unna believes 
that the process is essentially inflammatory. 

Diagnosis. — The disease should readily be recognized by the pecu- 
liarities of its seat, its course, and the nature of its symptoms. From 
ichthyosis it can be distinguished by the limitation of its lesions to 
the orifice of the hair-follicle; from the transitory condition known 
as "goose-flesh" by its persistence after the surface of the skin is 
thoroughly warmed; from papular eczema and the other lichenoid 
eruptions by the relatively insignificant character of the lesions, their 
evident follicular origin, and either the entire absence, or mild 
chronic type, of inflammatory symptoms. 

The disease is to be carefully differentiated from pityriasis rubra 
pilaris, in which the characteristic disorder of the scalp, the appear- 
ance of plaques of disease covered with fine pityriasic scales (often 
upon the tip of the nose and chin) exhibiting a peculiarly dark, 
smirched appearance, the affection of the nails, the characteristic pap- 
ules on the dorsal surfaces of the first and second phalanges of the 
fingers, and the evident admixture of the disease with symptoms 
of seborrho3'ic type, suffice to determine its nature. 

Though the lesions of keratosis pilaris bear little resemblance to 
the papular syphilodermata, many male patients for years swallow 
medicaments for relief of a supposed syphilis the sole " symptom " 
of which is a keratosis pilaris. The papular syphilodermata are not 
persistent year after year, are not throughout symmetrical, and are 
not limited largely to the outer faces of the limbs, especially of the 
thighs. They are preceded by a history of infection, and are accom- 
panied by other manifestations of the disease. They are not limited 
to the orifices of the hair-follicles, and are not capped by the peculiar 
horny scaling tip of the papule of keratosis pilaris. 

Treatment.- — For the subjects of keratosis pilaris in typical form 
it is not sufficient merely to order a bath. The bathing should be 
conducted systematically for years at a time. 

As soon as it can well be tolerated the patient should be urged to 
bathe the entire surface of the body every morning by the use of the 
sponge and cold fresh or salt water, following this with brisk fric- 
tion with a coarse towel or a flesh-brush. In other cases, warm alka- 
line baths are required. The habitual use of this cold bath con- 
tinued daily for years, in persons who can tolerate it (and patients 
affected with keratosis pilaris are usually of this class), accomplishes 
results of the most satisfactory character, exerting, as it does, a pro- 
found influence on the nutrition and healthfulness of the skin. 

For immediate treatment of the most of these cases, however, the 
hot bath with soap is desirable. This bath may be repeated as often 
as required to remove the lesions, and be followed in the more urgent 
cases by inunction with lanolin-pomades, or the fats or oils. Salicylic 
acid, 1 to 10 per cent, in oils or ointments, is effective in removing 
temporarily the horny accumulations. In the congenital and severe 
types, such as those described by Fox, cod-liver oil internally should 
be ordered. 



456 HYPERTROPHIES. 

KERATOSIS FOLLICULARIS SPINOSA (UNNA). 

i Ln in.x Pilau Spnroxosus [Radcliffe-Crocker and Adam- 

son]; LuiiiN Si'iM imsis [Divergie] ; A.cne Cobnjee [Hardy, 
Guibout, Leloir, Vidal, and Ballopeau] ; Keratose Folucu- 
laeke [Barbe ; Kebatobe Pilaiee Engainante [Audry] ; 
A.om Cornea < Kovannini 1 ].) 

Symptoms. — Keratosis spinosa in an affection similar in symp- 
toms and histological changes to keratosis pilaris, occurring most 
«»t'tcn iii children, in boys more than in girls, though occasionally it 
has been observed in adults. It is characterized by the development 
of filiform -pine-, projected from pilo-sebaceous follicles, the orifices 
of which become minute acuminate papules of a pinkish red hue. 
The eruptive symptoms may develop in acute or subacute type with 
agglomeration in patches especially over the buttocks, neck, trochan- 
teric regions, abdomen, popliteal spaces, and extensor aspect of the 
arms, often in crops. The face, hands, and feet are commonly spared. 
The itching is Blight. 

The horny spines project about one-sixteenth of an inch from 
the surface and can be picked out, leaving a depression in the centre 
of the papule. 

The disease was first described by Radelitfe-Crocker and Fox, 
though other English observers have recorded cases to the number of 
several scores, the disease, however, being admittedly rare in England. 
Its relationship with the several affections described by French and 
German authors under the titles given above is presumably close, 
many of the Continental cases recorded being identical with those de- 
scribed by English writers. The exact type of the disease as it occurs 
in England seems not to have been as yet described in this country. 

Etiology.- The cause of the disease is unknown. 

Histopathology. -Adamson describes a horny ping distending the 
upper third of the follicle and extending beneath the general level 
of the epidermis composed of concentric lamella; of flattened horny 
cells with acanthosis of the cell-wall. The chief contested point be- 
tween writers on this subject, concerns the question of inflammation 
as a preceding or coincident symptom. Adamson agrees with Rad- 
cliffe-Crocker and others thai the disorder is a hyperkeratosis, essen- 
tially admitting that at an early period there may be "congestion 
and Blight effusion around the follicle." Lewandowaky, 2 however 
found that his case was one of follicular inflammation with second- 
ary parakeratosis. By reason of the suppuration preceding the spine- 
formation in Lewandowsky's case the Knglish observers are disposed 
to exclude ii from the category of Lichen spinulosus, or Keratosis 
spinosa. 

Treatment. The treatment is that of keratosis follicularis and 
the prognosis favorable. 

1 Crocker, ■".<! <•<].. 1905, ]>. 452; Adamson, B. .1. 1>.. I'm."., xvii.. pp. 39 and 77 
(with lull bibliography to date, summary <>t' previously reported cases and 3 ex- 
eeUenl plates). 

- AjcMv, 1905, lxxiii.. p. 343. 



KERATOSIS SENILIS. 457 



KERATOSIS SENILIS. 



Symptoms. — The skin of the aged may become harsh, dry, and 
unusually cornified either diffusely or in certain definite regions, 
such as the hands, feet, or extremities ; this may be regarded as the 
simplest form of keratosis senilis. The skin of the entire body or of 
the region affected such as especially the face,- neck, and dorsa of the 
hands is then dark in color, dry to the touch, occasionally covered 
with fine, rather adherent scales, representing merely attached and 
cornified cells of the horny layer of epidermis, and notably unpro- 
vided with the natural unguent of the skin. 

In a more advanced grade the skin undergoes changes closely 
allied to epithelioma ; often, indeed, these both furnish the first symp- 
toms of epithelioma and coexist with its gravest destructive effects. 
The skin, more commonly of the face, the hands, or the forearms, 
less often of the feet, the legs, and the genital regions of the aged, 
is covered with thin, horny, often greasy-looking, pin-head- to finger- 
nail-sized and larger, dark-yellowish freckles, plates, or scales, between 
which the integument that has undergone the atrophic changes in the 
senile skin is visible. Pigmented puncta and macules may also 
appear scattered irregularly over the surface, with rough, dirty-yel- 
lowish to dark-brownish, granular accumulations upon the skin of 
certain regions, such as the clefts beside the alse of the nose, the 
temples, etc. When these warty, flattened, or elevated plaques are 
removed the underlying surface may be atrophic, excoriated, hemor- 
rhagic, or even ulcerated. The appearance is suggestive in some 
cases of a seborrhcea sicca of the face. In many patients exhibiting 
these features a fully developed papillomatous, superficial, or deep 
epithelioma may be present. In other patients one or more varieties 
of the senile wart may be visible, as described in the chapter on 
Verruca. 

The boundary-lines between senile keratosis and epithelioma are 
not well established. The exaggerated lesions of the former affection 
are frequently the first stages of the latter disease, and in the treat- 
ment of the skin of the aged, conducted on the general principles al- 
ready set forth, the physician should never lose sight of possibly 
serious consequences in one or more regions of the skin affected. 1 

Treatment. — In the earlier stages of this condition, the simpler 
methods of treatment may be effective, such as ablutions with toilet 
soap and water, or borax and water, followed by the application of 
one of the simpler salves. Pomades containing one to three per cent, 
of sulphur and salicylic acid or white precipitate (one part to fifty 
of cold cream salve) may be employed with advantage. Curetting 
lightly with ensuing applications of one grain (0.06) of bichloride 
of mercury to the ounce (30.) of tincture of benzoin may avert 
further trouble, as also painting with saturated solutions of pyoktanin 
blue in water. The salicylated plaster-mulls, and radiotherapy in 

1 Cf. Hartzell, J. C. B., 1903, xxi., p. 393 (bibliography) . 



458 HYPEBTBOPHIES. 

three minute exposures, with cessation on the slightest evidence of re- 
action, are exceedingly useful remedial measures. Radical treatment 
is desirable in all ease.- unmistakably epitheliomatoua in character. 

Prognosis.- The prognosis is to be formulated with due caution, 
in all ]>aiieiits with multiple Lesions, a suggestive change, t'<>r example 
in the face coexisting with several wartlike horny growths on the hacks 
of the hand-. The hygienic and simple treatment, outlined above, 
is often effective in delaying or preventing more serious degenerative 
changi -. 

KERATOSIS FOLLICULARIS. 

( Psorospermosis; Darter's Disease; Ichthyosis Sebacea Cornea 
[E. Wilson]; Keratosis Vegetans [Crocker]; Ichthyosis 

FoLLICUXARIS. /'"/•.. PSOROSPERMOSE FOLLICDLAIRE VKGETANTE; 
Ac\ I BEBAOEE OORNEE. i 

In 1889 Darier and Thibaull in France; White in America; and 
later. Wickham, Xeisser, and others, called attention to a cutaneous 
disorder not previously distinguished from other maladies. About 
fifty instances have been recorded chiefly by observers whose names 
are given in the appended bibliography. 

Symptoms. — In the cases reported the eruption was practically 
generalized, and exhibited first over the head and face but in greatesl 
abundance over the limbs, the front of the chest, the inguinal and 
genital regions, and the loins. In one of Bowen's cases the head and 
feet only were affected. The lesions were firm, pin-head-sized pap- 
ules, scarcely different in color from that of the surrounding integ- 
ument, which later assumed a deeper hue, and, whether flattened or 
hemispherical, these papules were soon covered with a grayish or 
brownish crust, greasy to the touch and apparently prolonged into 
depressions beneath, much as the crust of seborrhoea sicca of the face 
La -link within the orifices of the sebaceous follicles. The papules, as 
they increased in size and age, became darker in hue until eventually 
they were a deep brown and red, or even purple. A few exhibited 
scratch marks and were covered with hemorrhagic crusts. This was 
the classical picture presented in the patient examined by me at the 
first International Congress at Paris, and recognized by White as 
identical with that reported by him. 

Over the scalp the symptoms are practically those of the crusting 
forms of seborrhoea, save that there is no tendency to loss of hair. 
Over the face the parts chiefly involved are the temples, the inside of 
tin- concha of the ears, and the folds about the nose and lips. Here, as 
over the parts of the trunk named above, form dark, even blackish, 
strata of dirty oil-crusts, spontaneously shed. Beneath each crust, 
a< indicated above, there is usually a conical spur let into an infundib- 
ular depression, the latter representing the patulous orifice of a pilo- 
sebaceous gland. ( >ver the hacks of the hand and fingers the papules 
and crusts are less numerous, hut the papules are closely set together 
and tend to coalesce. In the palms and soles are numerous almost 



KERATOSIS FOLLICULARIS. 459 

imperceptible lesions of the same type. As the disease advances to 
what has been described as a second stage the papules coalesce, form- 
ing small dark-brown tumors and papillomatous growths, which in- 
volve not only the follicles, but also the interfollicular tissues. Many 
of the follicles become the sites of superficial ulcers, while the whole of 
the vegetating mass is bathed in a more or less abundant, fluid, muco- 
purulent secretion. The subjects of the malady often emit an offen- 
sive odor. 

The disease progresses gradually until large portions of the body 
are covered. Occasionally exacerbation with rapid spreading of the 
lesions occurs ; but, as a rule, the course of the affection is slow and 
the general health of the patient does not seem to suffer except sec- 
ondarily from the presence of ulcerating and suppurating lesions of 
the skin. 

Etiology. — Little is known definitely regarding the etiology of 
keratosis follicularis. In the majority of cases recorded it began in 
childhood, and in several instances in early infancy. Of the cases 
collected, the greater number of patients were males. 

The theory first advanced by Darier, and later elaborated by 
Wickham and others, that this variety of keratosis, and probably also 
Paget's disease, some superficial forms of epithelioma, and molluscum 
" contagiosum," were due to the presence of psorosperms or coccidiee, 
has been abandoned even by its propounders. As a result of further 
study by Bowen, Buzzi, Miethke, Boeck, Darier, and others, these 
bodies, which closely resemble certain psorosperms, have been demon- 
strated to be produced by cell-transformation. 

White's cases were in father and daughter, while Boeck had 
three cases in one family. Ehrmann 1 describes the case of a patient 
whose father he had seen in Janowsky's clinic with the same disorder. 
It is possible that contagion or heredity may have an influence in the 
production of the malady. 

Pathology. — The disease seems to be primarily a hyperkeratosis 
or atypical keratinization involving the sebaceous follicles and the 
hair-follicles. The process is confined for the most part to the neck 
of the follicle, but in the later stages it extends to the interfollicular 
tissues. The mouths of the pilo-sebaceous ducts are dilated into fun- 
nel-shaped openings and packed with masses of horny cells produced 
by the hyperkeratosis. Boeck and a few other observers believe, how- 
ever, that the process is not essentially follicular, but that it may 
begin outside the ducts. Bukowsky finds that the pathological proc- 
ess concerns not all but a limited number of the cellular ele- 
ments. 

The rete is usually thickened and in the later stages of the disease 
the interpapillary processes are prolonged. Mitoses are numerous, 
and in the lower layers of the rete are found fissures or lacunae, the 
exact significance of which is not yet determined. In places the 
pressure of the horny masses may produce thinning and atrophy of 

1 Abstr. in B. J. D., 1902, xiv., p. 41. 



460 HYPERTROPHIES. 

the rete. About the borders of the Lesions there is an abundant 
pigment deposit in both the epidermis and in the corium. The only 
other change noted in the corium is a small amounl of cellular infil- 
tration. The glands of the skin arc unaltered. Kreibich 1 in the 
ease of two women observed by him, recognized at the onset of a pso- 
rospermosis follicularis that there was a precedenl dermatosis re- 
Bembling zona, the lesions rapidly becoming transformed into the pap- 
ule.- of typical psorospermosis; and in his second case also lesions dis- 
posed like those of intercostal /osier appeared in successive develop- 
ment. The author believes that the disease should be classed with the 
inflammatory dermatoses of angioneurotic type. 

Constantin and Leverat 2 have given Darier's disease the name 
of pseudo-follicular dyskeratosis. The patient in Audry's clinic in 
whose case the skin lesions had been examined microscopically, ex- 
hibited numerous irregularities of the free surface of the epidermis 
with hypertrophy of the horny layer and pilo-sebaeeous or sudori- 
parous openings which formed pockets for the concretions of the 
horn cells. The epithelium immediately next to these plugs was 
altered; acantholysis had occurred with the result of the production 
of the so-called pseudo-psorosperm bodies. At the level of the ger- 
minative layer, cells of the rete were changed; the prickles had dis- 
appeared and the cells became separated from their neighbors. 

The round bodies formerly supposed to be psorosperms are found 
in the deeper and middle layers of the rete, and at the base of the 
horny plug tilling the follicle. According to Bowen, they are swollen 
cells containing a nucleus which stains deeply, and which is sur- 
rounded by a clear or hyaline ring of protoplasm, outside of which 
is a zone containing granules of keratohyalin, the whole being sur- 
rounded by a homogeneous, glistening membrane, which may possess 
a double contour. Various modifications of this type are found as 
a result of irregular keratinization of the cells. In the upper layers, 
in which the process of cornification is advancing, the keratohyalin 
gradually disappears; but it may do so irregularly, and losing its 
granular appearance, may give rise to appearances closely simulating 
nuclei and nucleoli. In the upper layers also the outer membrane 
may contracl or disappear, leaving an empty space. At the bottom 
of the horny mass in the follicle the si ral am granulosum is frequently 
absent, and there are seen irregular, shrunken, homogeneous cells with 
nuclei which stain hut feebly. These cells are the "grains " of Darier 
and Bowen believes they are cells which have become cornified without 
passing through the keratohyalin stage. 

Diagnosis.- The disease is to be differentiated from molluscum 
epitheliale, which is never so generalized, and which always exhibits 
an enucleable mass containing the so-called "molluscous bodies." 

'Archiv, lxxx.. p. 367; Zum Wesen der Psorospermosis Darier, Archiv, Ixxx., 
|.. 867; AJinales, L907, 8. Lv., viii., p. 302. Nfalinowski, Die Dariersehe Knuik- 
heil Psorospermosis follicularis vegetans, Mfonats., xliii.. p. 209. 

'Keratosis Follicularis A Ww Case of Pseudo-Follicular Dyskeratosis of 
Darier, Ajmales, L907, b. Iv., viii., p. 887; B. J. D., L908, xx.. p. 204. 



PLATE XVIII 




I 



Keratosis Punctata In a Man who had been taking Arsenic 
for a long-standing Psoriasis. 



KERATOSIS FOLLICULARIS. 461 

The papular forms of acne are eruptive elements which contain cen- 
trally a true corneous mass ; in keratosis f ollicularis there is a softish 
comedo-like central mass. The acne-forms, further, are not general- 
ized. The disease bears close resmblance to some forms of ichthyosis, 
but a careful study of the history, the character, and location of the 
lesions will usually make the diagnosis clear. Acanthosis nigricans 
is far more localized. 

Treatment. — The treatment is still undetermined. While marked 
improvement may be obtained, no complete recovery has been re- 
ported, and with a lapse in treatment the unfavorable condition of 
the patient quickly returns. The parts are to be well cleansed by 
shampooings, and then dusted with borated, salicylated, and absorbent 
powders. The French, acting upon the parasitic theory of the nature 
of the affection, vigorously employ parasiticides, salves containing 
salicylic acid, sulphur, ichthyol, resorcin, pyrogallol, or iodoform, 
and even resort to cauterizations with zinc chloride. Lieberthal and 
Mook seem to have employed radio-therapy with satisfactory results. 

The prognosis in general is unfavorable. 

KERATODERMIA PALMARIS ET PLANTARIS. 

(Symmetrical Keratodermia of the Extremities, Congenital 
Keratoma of the Palms and Soles, Ichthyosis Palmaris 
et Plantaris, Tylosis Palmarum et Plantartjm; Fr., Kera- 

TODERMIE PALMAIRE ET PLANTAIRE.) 

Symmetrical and deforming keratosis of the palms and soles, 
sometimes of one set of organs more conspicuously than the other, 

1 Darier et Thibault, Annales, 1889, s. ii., x., p. 597, and These de Paris, 1889. 
Darier Intern. Derm. Congress, Paris, 1889, and Intern. Atlas of Bare Skin Dis., 
1892, Part 8, ii. White, J. C. D., 1889, June, and 1890, January. Boeck, Archiv, 
1891, xxiii., p. 857. Lustgarten, J. C. D., 1891, Jan. Buzzi and Miethke, 
Monatshft., 1891, xii., p. 9. Neisser, Second Intern. Derm. Cong., 1892, Arehiv, 
Erganzungsheft, 1892, xxiv., p. 80. Schwimmer, ibid., p. 76. Schweninger und 
Buzzi, Intern. Atlas, 1892, Part 8. Pawloff, Archiv, xxv., Erganzungsheft, 1893, 
p. 195. Fabry, Archiv, 1894, xxvii., p. 373. Mourek, ibid., 1894, xxvi., p. 361. 
Jarish, ibid., 1895, xxxi., p. 163. Neumann, Wiener klin. Woch., 1896, No. 3. 
Bowen, J. C. D., 1896, June. Hallopeau et Darier, Annales, 1896, pp. 737-742. 
Bowen, ibid., 1898, p. 6 (case limited to feet and hands). Melle, Giorn. Ital., 
1898, p. 365; Eef. Annales, 1899, p. 506. Jacobi, Verhandl. d. Deutschen dermat. 
Gesell. VI. Congress, p. 406, 1898. Caspary, Festschrift, Kaposi, 1900, p. 199. 
Ehrmann, Wiener med. Presse, 1901, No. 46. Hallopeau et Fouquet, Annales, 

1902, p. 228. Schwab, Inaugural Dissert. Freidburg i. Breisgau, ref. Annales, 

1903, p. 627. (This case seems to be identical with that of Jacobi.) Weidenfeld, 
Archiv, 1903, Ixiv., p. 275. Ormerod and MacLeod, B. J. D., 1904, xvi., p. 321. 
Lieberthal, J. A. M. A., 1904, July 23. Mook, Abstr. Monatshft., xliii., p. 362. 
Curl, J. C. D., 1905, xxiii., p. 403. Kreibich (with plates illust. two cases), Archiv, 
1906, lxxx., p. 367. Malinowski, loc. cit. (case, 2 cuts, bibliog. to date). Sachs, 
O., Wien. klin. Woch., 1906, Nos. 10 and 12 (abstr., Monatshft., xlv., p. 164). 
Bukofsky, Archiv, 1905, lxxv., p. 279 (case, 4 figs, showing path, sections). Fasal, 
Archiv, 1905, lxxiv, p. 13. Jamieson, Keratosis follieularis, Edinburgh med. 
Journ., 1907, p. 32; Annales, 1907, s. iv., viii., p. 350. Constantin et Levrat, 
Keratosis follieularis: Sur un nouveau cas de dyskeratose pseudo-folliculaire de 
Darier, Annales, 1907, s. iv., viii., pp. 337-344. Stout, Keratosis Follieularis, 
Philadelphia Derm. Soc, J. C. D., 1907, xxv., p. 125. 



46: 



HYPESTR0PHIB8. 



was iir-i definitely described in a communication made by me to 
the American Dermatological Association in 1S87 and later more 
fully by CTnna in Germany, and by Besnier and Doyon, in France. 
Since then ;i number of important observations have been made on 
the subject, for the mosl part named in the appended bibliography. 

Symptoms.— ( )b-M-rvai ii«n of the cases recorded under the several 
titles named above, disclose the fad thai they differ very greatly 
not merely in their symptoms bul in their etiology. The chief symp- 
tom common to all is merely a corneous thickening of the palmar and 
plantar surfaces. The other conditions, in the different groups 

named below exhibit wide variations. 

Congenital Palmar and Plantar Keratosis. — This is the rarer of the 
forms included in the list, though statements to the contrary have 
been made by several observers. Soon after birth, the palms and 
Boles of the infant are found to be generally and uniformly covered 
with a dense thick corneous mass, less plate-like than in the other 




types of tli<' malady, and more rugous, verruciform, and cumbersome. 

The outline of the keratomatOUS patch is definite, commonly not 
extending to the dorsa of the affected organs; and rarely associated 
with hyperidrosis or environed with a pinkish halo. Instead of 
presenting the Bpecies of opaque dirty yellowish cast of the palm and 
sole Been in other cases, the parts are overspread with a dark-hued, 
oft< ii brownish or blackish wart-like integument, exhibiting rugous 



KEEATODEBMIA PALMABIS ET PLANTABIS. 463 

elevations and between the latter depressions preventing full extension 
of hands and feet. The hollow of the foot and the centre of the palm 
are often not spared. The hands and feet are commonly equally and 
symmetrically involved. The condition resembles certain " hystrix " 
forms of ichthyosis. The teeth and hair may not be involved. 

Acquired Palmar and Plantar Keratosis. — This is by far the most 
common of the conditions heretofore included in the list, and the 
symptoms are markedly different from those exhibited in the con- 
genital forms described above. 

The Hyperidrosis Type. — In this form of palmar and plantar 
keratosis, there is invariable association with hyperidrosis, a con- 
dition upon which the keratoma is implanted and which is its chief 
etiological factor. The hands and feet, or hands only or feet only 
may be involved, usually symmetrically. The condition of hyperi- 
drosis may be mild or exaggerated, and be dependent upon one of the 
toxic causes sufficient to interfere with circulatory equilibrium — 
(alcoholism, prolonged tobacco-narcosis, excess in use of sugar, tea, 
meat, etc., delicacy of constitution, cardiac disorder, etc.). The palms 
and soles are at first merely reddened, cool, and damp. Later, kera- 
tosis develops about the palmar faces of the fingers or toes, about the 
heel in a ring or over the hypothenar eminences. When fully de- 
veloped, the instep, arch of the foot, and centre of the palm are com- 
monly spared, being of normal color and moistened with effused sweat. 
For the most part the other palmar and plantar surfaces of hand, 
foot, fingers, and toes, are covered with a dull yellowish-hued cuirass- 
like plate well defined in contour and surrounded at the border by a 
delicate moist halo or areola of non-cornified epidermis the seat of pas- 
sive congestion. The affection is seen in all grades, often the exte- 
rior face of the plate, especially over the heel, has a pitted aspect, due 
to irregularity of accretion of the horny substance. Very marked 
pitting with a nutmeg-grater-like appearance of the plate is often 
observed as in arsenical cases. Indeed many patients with hyperi- 
drosis and palmar and plantar keratosis have taken arsenic under the 
direction of a physician. 

The condition may persist, or greatly improve under appropriate 
treatment ; or, even without treatment, almost wholly disappear under 
improved conditions of the general health and a duly regulated hy- 
giene. The thickness of the plate may be one sixteenth to one eighth 
of an inch. Patients often complain bitterly of the soreness and 
discomfort induced by the presence of the calloused masses, locomo- 
tion when the feet are involved being in some instances greatly im- 



In these cases the nails are usually in greater or less degree in- 
volved, the free border being up-tilted away from the phalanx of the 
digit, as well as thickened and at times even gryphotic. 

The Arsenical Type. — So many instances of keratosis involv- 
ing the palm and sole have been treated by arsenic that no little ob- 
scurity obtains respecting the pure types of the one and the other, yet 



464 HYPERTROPHIES. 

a sufficient number of instances are <>n record where the clinical fea- 
were solely due to the medication. 

When a keratosis of the palm or sole is due to arsenic, there is 
rarely, either, first, a rugous condition of the ichthyosis-type seen in 
congenital cases; nor second, the production of a relatively smooth 
dirty-yellowish pined plate as in the hyperidrosis cases. Instead the 
palm or Bole, occasionally the lateral surface of the digits in classical 
cases is rough, dry, thickened, and diffusely covered with smaller and 
larger discrete dirty-grayish warty projections from the plane of the 
normal skin. Some of them resemble ordinary warts; others are 
closely packed pin-head-sired papule-like bodies: yet others, in ad- 
vanced cases, where the metal has for long been ingested, are much 
larger warty growths developing eventually into cancerous formations 
(epitheliomata, Hutchinson's "arsenical cancers"). Upon the sole 
the tendency is toward larger excrescences, especially over the poste- 
rior arc of the heel and the distal pari of the metatarsus. In determin- 
ing the nature of this change inspection of the skin of other regions 
of the body discloses often deep pigmentation in characteristic shades 
of dirty brown. In the arsenical cases, according to Hamburger, 1 
the coloration is found in the corium, the epidermal cells being non- 
pigmented, dark granules of uncertain chemical composition, lying 
about the vessels in the papilla? and in the advent itia of the vascular 
walls. 

For the melanoderma with verrucous alterations, and later opi- 
theliomatous growths due to ingestion of arsenic, consult the chapters 
devoted to these subjects. 

Palmar and plantar keratoses occur in men whose trades and occu- 
pations invite the occurrence of the changes described above. These 
are instances of compensatory cornincation, protective in character, 
precisely as in the keratoma of the hyperidrosic patients, when there 
is increased vulnerability of the moistened skin. Often the special 
character of the labor pursued induces the callosity of palm and sole, 
as, for example in those who have to work in water and at the same 
time handle rough material- such as tiles, clay, plaster, etc. 

The chief keratoses of the palms and soles may be usually assigned 
to one or another of the groups designated above, though a failure to 
recognize the relation between effecl and cause is the source of con- 
tusion in attempts to classify the facts recorded. Brocq's "band- 
like*" form may have been due in part to the occupation of the in- 
dividual : Besnier's inflammatory halo about the lesions, and Brooke's 
"erthema keratodes" of palms and solos represent simply the often 
noted erythema stage, antedating the fully advanced keratomatous 
condil ion. 

Etiology, In congenital cases the condition may be recognizable 
at birth by an expert, though commonly it is not appreciated by 
parent- of the child until months have elapsed and the morbid con- 
1 Johns Soap. Bull., April. 1900, p. 89. 



PLATE XIX 




Palmar Keratosis, due to Arsenic. 



KEBATODEBMIA PALMABIS ET PLANTABIS. 465 

dition has fully developed. In some cases, there is a coincident 
change in the teeth, hair, and nails. In others there is a history of 
similar disorders in other members of the family, immediate or re- 
mote. In some instances it is congenital and hereditary. Vomer 1 
reports the disease as occurring in four generations, sixteen out of 
forty members of the family being affected. Other instances in 
which the disease occurred through four generations are reported by 
Brayton, Decroo, and Pasini. 2 

In the acquired hyperidrosis cases the nails are often affected and 
sooner or later etiological factors are evident in the embarrassment of 
the circulation. The heart, lungs, nervous centres, or general bodily 
health may be responsible for the keratoma. Sometimes there is 
marked tachycardia, in others bradycardia ; in yet others, the kidneys 
are at fault. Grave changes in the palms and soles are occasionally 
associated with desquamative nephritis and albuminuria. 

The arsenical and traumatic cases (those due to exposure of the 
hands and feet in the trades) have an origin that explains itself. 

Pathology. — Vomer states that all the layers of the skin involved 
are thickened uniformly and that cornification is normal in type but 
excessive. He found no evidence of inflammation. Pasini reports 
very great increase in the number of sebaceous glands. Other ob- 
servers describe marked elongation of the interpapillary processes with 
dilatation of the blood-vessels and the formation of irregular horny 
masses over the papillae. 

Diagnosis. — The diagnosis of all forms of keratosis of the palms 
and soles is to be made from eczema, chiefly by reason of the absence 
of well-marked inflammatory symptoms, of vesicles, and of eczematoUs 
patches in other regions of the body. Palmar and plantar syphilides 
are to be distinguished with great caution. These last may be asym- 
metrical, especially if of " late " type ; may exist where there is often 
a history of infection or signs of lues ; and may often ulcerate. They 
have also well-defined circinate borders; and the lesions are more 
often multiple and isolated. 

Treatment.- — -Internal treatment is preeminently indicated in all 
the hyperidrosic cases ; and should be employed to meet the indica- 
tions present. Abstention from tobacco, coffee, tea, and alcoholic 
stimulants, is in general demanded. The arsenical cases may be 
greatly improved by cessation of the medication. Brocq advises the 
internal administration of sodium arsenate in large doses; but in 
this connection it should be remembered that cases are reported in 
which keratosis of the palms and soles has apparently been produced 
by a long course of arsenic. The local treatment is by prolonged 
maceration of the parts, followed by shampooings with green soap in 
substance or tincture, followed by salicylated pastes, plasters, or solu- 
tions of salicylic acid in collodion. Mercurial plasters and mercuric 
oleates may also be used with advantage. Potassium hydroxide in 10 



Archiv, 1901, lvi., p. 3 (bibliography). 

Griorn. ital., 1902, xxxvii., p. 318 (bibliography) . 



30 



466 HYPEETEOPHIES. 

to i'»' per cent strength has been applied as a lotion to stimulate the 
Other formulae recommended arc salicylic acid and calomel, 
1 pari of each to 20 parts of glycerole of starch; and 1 part each of 
resorcin, tartaric acid, and salicylic acid, to 20 or 30 parts of the 
Balve-basia. 

In 3 cases we have obtained very marked improvement with a 
t\\v applications of the ay-rays. In one congenital case, that of a girl, 
five years, of age, a keratosis involving the entire surface of both 
palms and soles, and so severe as to prevenl extension of the fingers 
and to interfere with walking, disappeared almost entirely after 16 
treatments daring a period of six months. Eighteen months later the 
keratosis had not returned. 

Prognosis. In the inherited and congenital cases complete re- 
moval of the disorder is accomplished rarely, but by continued treat- 
ment the >kin can be kept soft and the patient more comfortable. It 
must not be forgotten that hyperkeratosis of the palms and soles, or 
of other parts of the body, may terminate in epithelioma. 1 

KERATOLYSIS EXFOLIATIVA CONGENITA^ 

The shedding of what practically corresponds to the epithrichial 
layer, occurs in new-born infants and is exhibited in the form of 
branny desquamation lasting for a week, ten days, or more after 
birth. From what precedes in the paragraph devoted to the general 
considerations of keratosic changes in the skin, it will be clear that in 
some cases the epitrichial layer is not thus normally shed but, as Leng- 
let has suggested, takes on, as it were, an independent existence and 
continues in adult years with the production of more or less persistent 
desquamation and exfoliation. 

Under the title "Keratolysis Exfoliativa Congenita" Sangster 8 

'Bibliography: Unna, Archiv, 1883, p. 231, report of 2 cases. Hyde, fifed. 
News, ii.. 1887, p. 41f>. 3 cases. Hyde and McEwen, J. C. D., 1904, illust. cases 
associated with hyperidrosis. Byde, Morrow's Syst., iii., p. 405. Brocq, Traite- 
iii. -tit des Mai. de.la Peau, 2d ed., p. 376. Brooke, B. J. D., 1891, pp. 335 and 19. 
Vomer, Archiv, 1901, Ivi., 1901, p. 3. Dale. Brit. Med. Jour., 1887, Oct., i., p. 718 
( Mai de Meleda). Havorka and Elders. Archiv, 1^ ( .»7. xl.. p. 251. Besnier. Kera- 
todermia symmetrica erythematosa, [nternat. Atlas Belt. Bautkrank., Heft ii., 1887. 
White, C. J., Keratosis palmaris et plantaris hereditaria, Boston Derm. Club 
Cutan., 1903, xxi., p. 289. Hallopean, 11.. Bur une erythrodermie mycosique avec 
hyperkeratose plantaire el palmaire et peut-etre neoplosie initiate, Annales, 1896, 
s. iii., \ii., 522 52 1, also, Bur on hyperkeratose palmaire et plantaire localises auz 
orifices sudoripares et sur Ie role dee orifices glandulaires dans les neoformations 
epidermiqnes, Annales, ls<ir>, s. iii., xi., p. 480-482. Schiitz, Tylosis l'alniaruin 
in the A. hilt I n. I. •pendent of Pressure, Archiv, Bd. 59, 1902, p. 57; B. J. P.. xiv., 
L902, p. 320 f lYier die vom Druck unabhangige Tylosis palmarum der Erwach- 
senen). Decroo, Primary congenital and hereditary case of Keratosis of the Palms 
and Boles, J. des s.-i. Med. de Lille. No. 27, L903, p. 11; B. J., 1903. xv., :577 (ex- 
isted iii four generations two brothers, Hire usins, one daughter (also errand- 
father and father and uncle), other members in ea.di generation not affected. 
Allen. Keratosis of the Palm, X. Y. Menu. Soc, C. G. I'.. 1899, p. 576. Piffard, A 
Case of Keratosis (Multiple) of the Palms and Soles, \. V. Derm Soc. 0. G. U., 
lso'.i, p. 373. Awirv et Dalous, Byperkeratose circonscrite des doigts ehes un 
syringomyalique, J. tnaL cut., 1902, 6s., xiv., 412 4 1 r>. Oh. Audry, Dyskdratose 
palmaire an cours .rune ichthyose irritable, J. Mai. Cut., 1903, 6s., xv., 566-567. 

3 B. .1. 1).. 1S9"., \ ii., :i7 (photographic plate). 



POROKEBATOSIS. 467 

and later Rasch 1 have described these conditions, the former in the 
case of a man 2i years of age in whose case the desquamation began 
at the third week of life, became universal at the end of the third year, 
and afterward persisted with constant exfoliation in large sheets. 
There were also areas of infiltrated skin divided in quadrilations. 
The palms and soles were thickened and sodden from hyperidrosis 
with no exfoliation in these regions. The pruritus was severe and 
there were infected points as the result of scratching. Where the 
loosened epidermis had been removed, the skin for some hours was 
blanched ; the hairs and nails were unaif ected. 

Rasch' s case was somewhat similar though the skin was reddened, 
the author suggesting as a title for the disease, Ichthyosis rubra. 
'This was evidently one of the types of keratolysis described by the 
French as lamellar exfoliation of the skin of the new-born. 



MAL DE MELEDA. 

Mai de Meleda, described by Salli, Iiovorka and Ehlers, 2 Neu- 
mann, and others, is a disease recognized on the Island of Meleda off 
the Dalmatian Coast, in which occurs a congenital keratosis, not ex- 
clusively involving the palms and soles, but the lower portions of both 
extremities. There is some ichthyotic thickening of the skin which 
also exhibits blackish points supposed to represent the orifices of the 
sweat-ducts. The odor emanating from the parts is offensive when 
seborrheic accumulations also occur. Radcliffe-Crocker believes this 
endemic affection to be in part due to intermarriages. The supposi- 
tion that it is a form of leprosy has been abandoned. 

POROKERATOSIS (Mibelli). 3 

(Hyperkeratosis Excentrica (Respigrt), Keratodermia Excen- 
trica, Hyperkeratose Figttree Centrifuge Atrophiante 
(Respig-hi).) 

This rare dermatosis was first described by Mibelli, his cases hav- 
ing been recorded in 1893; since that date about two score of 
patients affected with the disease have been seen in Italy, America, 
Germany, and Hungary, the observers in these countries being for the 

1 Derm. Zeitsch., 1901, viii,, 669; Abs. B. J. D., 1902, xiv., 110 (cited by 
Crocker) . 

2 Archiv, 1897, xl., p. 251. 

3 Bibliography : Mibelli, Giorn. ital., 1893, p. 313; Monatshefte, xvii., p. 417,* 
International Atlas of Eare Diseases of the Skin, 1893, xxvi.; Bibliography to 
date, Archiv, 1899, t. xlvii., p. 231. Hutchins, J. C. D., 1896, October. Gilchrist, 
J. C. D., 1899, April. Wende, idem, 1898, November. Aberastury, Anales del 
circulo medico argentino, 1899, t. xxiii. Wolff, Verhandlungen der deutschen 
dermatologischen Gesellschaft, IV. Congres, Vienna, 1899, p. 387. Hartung, 
Archiv, 1901, t. lvi., p. 147. Basch, Pester meclizin.-chirug. Presse, 1898, No. 27. 
L. Nielsen, Derm. Zeitschr., 1903, p. 597. Larrode, These, Bordeaux, 1900. Aude- 
bert-Lasrochas, These, Paris, 1902. Galloway, B. J. D., 1901, p. 262. Joseph, 
Archiv, 1897, xxxix., No. 3. Kullak, Dissert, inaug., Berlin, 1901. Heller, Derm. 
Zeitschr., 1899, p. 691. Heidingsfeld, J. C. D., 1905, January. 






HYPERTROPHIES. 



most pari named in the appended bibliography. In 1905, Mibelli 
reporting two new cases observed by himself, took occasion to remark 
that the instances described by Joseph, Heller, and Heidingsfeld were 
ii"! identical in character with those which he has recorded. The 
following description is a brief abstract of the features of the disease 
9cribed by Mi belli. 
Symptoms. Porokeratosis is an inherited, chronic, and progres- 
sive keratoatrophoderma, which persists -luring life. Its elementary 
lesion is a definitely denned superficial spot, which is essentially a 
small keratosic collar, sharply elevated above the general level of the 
skin like a dike or -cam. enclosing a slightly atrophic integument 



Pro. ::;. 




(Douglass Montgomery, i 



The dike or limiting wall is in section, triangular, having a prismatic 
outline, with a tortuous contour producing more or less sharply 
bordered figures, yellowish-gray or brownish in hue, horny in char- 
acter, Burmounted by a dry, firm, delicate, projecting crust, which 
seems to spring from a slender furrow running along the summit 
at the dike, constituted of a spur rising from the horny layer of the 
epidermis. 

The elementary lesion is this minute homy spur, firm, dry, 
pointed, and Bpringing from the orifice of a cutaneous gland, about 
which forms the minute collar referred to above, constituted of slender 
flat-topped horny lesions which may fuse. As gradual extension of 

the disk ensues, the central portion l>ec es progressively depressed. 

Where the skin is delicate and covered with lanugo-hairs (buttocks, 
thighs, and Legs) the skin of the enclosed area presents only a smooth, 



POROKERATOSIS. 469 

slightly atrophic appearance, the larmgo-hairs being generally absent. 
Keratosis in these parts is represented chiefly by the dike or wall; 
there may be, however, minute projecting horny lesions in the central 
area representing the orifices of the cutaneous follicles. 

On the backs of the hands where no irritation has been produced 
by reason of friction, etc., incidental to the trades and occupations 
of life, the hyperkeratosis is much more pronounced, the collarette 
larger, firmer, and more elevated than elsewhere, while the central 
area is remarkable for its dryness. 

As the process extends centrifugally, there is persistence until 
atrophy occurs of the orifices of the pilo-sebaceous pouches and the 
sweat-pores. Situations where these features are pronounced are: 
the face, the scrotum, the axillae, the pubic region, and the hairy 
scalp. 

On the disappearance of the hyperkeratosis the surface becomes 
shiny, atrophied in various degrees, and the normal furrows of the 
skin somewhat more separated. The hairs are usually, not always, 
absent ; and there is more or less peripheral pigmentation. 

In such special regions as the face for example where the glands 
are numerous the atrophic condition is less distinct, the isolated 
horny projections often absent, and the peripheral collarette much 
more slender. The appearance then is that of a delicate atrophy of 
the skin. 

In regions where there is external pressure the reverse occurs, 
for example, over the dorsum of the toes. Here the keratosis is more 
developed, the atrophy more pronounced. The impression to the eye 
is then suggestive of a dermato-sclerosis. In the palmar and plantar 
regions and on the lateral surfaces of the fingers the appearance pro-, 
duced may be that of a soft corn ; but the characteristic collarette 
suffices to establish the distinction. 

Etiology. — The causes of the disease are not known. Eleven 
cases reported by Gilchrist occurred in four generations in one family. 
The record of other cases indicates clearly that the disease, or the 
tendency to it, is inherited and, as Mibelli points out, often limited to 
members of a single family. 

- Pathology and Histology. — The horny layer in these cases is the 
seat of a hyperkeratosis the normal epidermis being, especially in the 
basal layer, increased in thickness ; the granular layer is here and 
there also increased in dimension. At the level of the collarette the 
hypertrophy of the horny layer is increased and produces the pro- 
jection from the free surface of the skin, which is its marked clinical 
feature. 

On the inner face of the rete when detached from the corium, 
throughout the length of the collarette, a crest extends in exact cor- 
respondence with that which is elevated above the general level of 
the surface. In the region of the furrow the epidermis is thin, com- 
pressed, and deprived of the granular layer. The horny part which 
fills the furrow is simply an hypertrophied mass of epidermal cells of 



47«» HTPEBTB0PHIE8. 

atypical cornincation. This i> in exact correspondence and con- 
tinuity with tin- hypertrophy of the horny layer beneath, the pecu- 
liarities of the "•like"' and the furrow being wholly due to this ar- 
rangement. 

Treatment. The treatment is unsatisfactory. Electrolysis and 
excision have Keen followed by comparatively satisfactory results; 
though recurrence often takes place and in mosl instances the disease 
ats indefinitely. 

ANGIOKERATOMAS 
(Kbratoaxgioma, I.ym iMi.wi.ii < tasis (Colcotl Fox). /•'/•.. Am.Io- 

CERATOMEj T I 1 \ N I ■ I I I 1'ASI K VEBRUQUEUSE (BrOCq), VeRRUE- 

Ti i . Wi.n < rAsiQUE ( Dubreuilh I. I 

Angiokeratoma i~ a disorder characterized by the appearance of 
pin-head-sized and Larger vascular dilatations, upon which are devel- 
oped later wart-like elevations. The disease occurs usually on the 
extremities of individuals subject to chilblains. This affection was 
described first in 18S'.» by Mibelli; later, cases of a similar character 
though differing in many details have been reported by Thibierge, 
Crocker, Pringle, Joseph, Wisniewski, and others. The cases are 
rare, and tiny apparently occur with wide divergence of type. 

Symptoms. — The lesions may be first recognized upon the hands, 
where they resemble ordinary perniones, and are seated on the dorsal 
aspect of the toes and fingers, especially of individuals who are much 
exposed to low temperatures or who handle cold substances in the 
trades, as, for example, those who dress cold beef in winter. Both 
the palms and the soles may be invaded. We have had under observa- 
tion typical cases in which the lesions existed exclusively on the 
scrotum. Other instances of angiokeratoma of the scrotum are on 
record by Fordyce and others. Here, as over other regions of the 
body involved, the lesions may be discrete or closely commingled, 
pinhead-sized and larger translucent, horny-capped, roundish warts, 
Illinois. ( .r nodules, at iirst pinkish, dull reddish, later purplish in 
color, leaden-hued, or even chocolate-tinted, interspersed with flat mac- 
ules (split-pea sized for the most part, having a dark central punc- 
iuin ). which are at first removable by pressure and which eventually 
persist. These lesions are often mere cutaneous varices. The glob- 
oid nodules may he smooth and horny at the surface or he roughened 
and prickly; they are never scaly. Occasionally pedunculated vaa- 

'Bibliography: Mibelli, Giorn. ital., 188!). xxx.. p. .~ u 7 ; Monatshefte, L895, 
xx.. p. 309; Giorn. ital., L891, L59. Pringle, B. J. I>., L891, iii., pp. 2:i7. 282 and 
809 (clinical and histological illustrations, with review of published cases). 

Wisnicwskv, Arcliiv. 1S<IS, xiv., p. .V.7 ( liililio^raphy and Cuts showing histology). 
<'r..<-kcr. B. .1. 1).. 1891. Mibelli, Atlas Int. Rare T)is. of Skin. 1890, f. 21. Thi- 
l.icrK<-. Amwilcs. 1S92, 1159. Joseph. I '.. rl. klin. Woch., L902, 20. Barin, Affect, 
cutan. artificiclh'H, 1S(!2. \'u . Scchovron, Arch. gen. de Mt''d., 1886, 819. Du- 
breuilh, La Brat. Derm.. 19(10. i.. VSA ■ Annul. <!.- In Bolvelin. do Bord., 1SS9, Jan.; 
Aimales, Is'.*.".. "<»; S,„-. mod. ,!.■ Bnrdoanx. ls'W. May" 12. Zoisler, Trans. Amor. 

Derm, Ass., is<t.!. Fordyce, J. C. D., 1896, 8, colored plate and 5 miorophoto- 
graphs. 



ANGIOKERATOMA. 471 

cular tumors may develop. At times the varicosities of vessels are 
commingled with both spots and nodules, transitional forms occurring 
in some cases. The arrangement of the lesions is in general irregular 
and asymmetrical, though there may be grouping. There are no sub- 
jective sensations. The affection is regarded as of so little moment 
by some patients that the lesions have been recognized in examining 
the skin for relief of another disease. 

Etiology. — The patients are commonly young, but a few cases 
have been reported in middle-aged subjects. There is usually a his- 
tory of exposure of the affected parts to cold weather or to cold sub- 
stances as described above. Some of the sufferers from the disorder 
seem to have been subject to chilblains. 

Frohwein 1 considering the case of a woman, 17 years old, who 
had suffered in the hands and feet especially during the cold seasons 
of the winter since the seventh year of life, calls attention to the fre- 
quent coexistence of angiokeratoma with tuberculosis of internal 
organs. i 

Pathology. — The first change is a dilatation of the blood-vessels 
of the papillary layer to form punctiform capillary varices. The 
blood-stasis is followed by hyperkeratosis of the epidermal cells. 
Fordyce describes small spaces filled with blood in the papillary layer 
of the cutis, and also in the rete. He explains their occurrence in the 
rete by the supposition that the down-growth of epithelial cells sur- 
rounds and cuts off some of the terminal vascular loops in the papillae. 
There are, in addition, slight evidences of inflammation in the cutis 
beneath the lesions, and a marked thickening of the horny layer. 

Diagnosis. — Angiokeratoma is to be distinguished from super- 
ficial lymphangiomata, by the early age at which the latter first ap- 
pear, by their location, and by the pseudo-vesiculation which they ex- 
hibit, as also by the contents of the lesions. Verrucse vulgares occur 
as simple hyperkeratoses, uncomplicated with vascular dilatation. 

Dubreuilh limits the term angiokeratoma to the lesions occur- 
ring in childhood as a consequence of such exposures as invite chil- 
blains ; and excludes from the category all cases of multiple angioma 
whether keratosic or not, congenital or senile, seated in other regions 
of the body than the hands and feet. He thus excludes all the scro- 
tum cases (Fordyce' s and our own) which he terms capillary varices ; 
cases like Zeisler's (pedunculated angio-verrucous tumors dissemin- 
ated over the body) ; and Moure's kerato-angiomatous lesions of the 
vocal cords. 

Treatment. — The treatment is by stimulating lotions and lini- 
ments, as in pernio, and, when required, by destruction of the vascular 
warts with electrolysis or galvano thermo-cautery. 

Prognosis. — The prognosis is favorable, as the lesions may be 
made to disappear under proper treatment. 

1 Monats. f. prakt. Derm., 1907, xlii., 349. 



472 II ITER TEOPHIES. 

KERATOSIS FOLLICULARIS CONTAGIOSA. 

A.< \l'. si -.!■• a. BE i,ii;nkk.I 

II. G. Brooke 1 described under this title a rare and apparently 
contagions disorder occurring in children and occasionally in adults. 
Blackish and yellowish Mack macules were symmetrically developed 

into deeply pigmented papules over the face, neck, the shoulders, and 
the extensor faces of the arms. From these papules protruded 
blackish specks, which later resembled comedo-plugs and eventually 
developed as Bpike4ike filaments. The skin, however, was dry, never 
gn asy, of a dirty shade of color: and the thorny excrescences wore at- 
tached firmly to the tissue beneath. We have had under observation 
two young women who exhibited precisely the same features on the 
extensor surfaces of the arms, forearms, thighs, and legs. Unna 
divides the pathological symptoms into those due to retention and 
those due to the formation of horny plugs at the sites of the follicles. 
The lesions are distinguishable from those of acne and comedo by the 
absence of sebaceous cells and by their collar of horny lamellae at the 
base. The spokes are produced by the energy of the hyperkeratosic 
process, which pushes the horny plug outside of and beyond the fol- 
licle, its upper segment only being concerned in the process. The 
disease is essentially a hyperplasia of the epithelial cells, the first evi- 
dence of the operation of the external cause being apparent in the 
stratum granulosum, the chief result, being declared in the common 
exert tory duct of the pilo-sebaceous conduit. The disease was readily 
relieved by applications of lard saponified with potassium hydroxide. 

HYPERKERATOSIS STRIATA ET FOLLICULARIS. 

II. v. Ilebra 2 reports under this title the case of a young woman 
with isolated epidermal elevations, having a reddish margin, of both 
superciliary arches, over the bridge of the nose, the upper lip, the 
throat, shoulders, and arms. The lesions were flat or elevated, iso- 
lated or confluent nodules, constituted of heaped-up epidermis, which 
could be removed without disturbing the papillary layer of the corium. 
Many were bean-sized, grayish-green elevations, conspicuous over the 
elbows, wiili underspreading epidermic cones buried in corresponding 
depressions beneath, which often bled freely when the cuticular mass 
was removed. Contrasting with these lesions were striated elevations 
of epidermis extending either at an angle or along the longitudinal 
axis of the limb. The disorder was relieved by warm-water and 
soap baths, followed by resorcin-vapor and salicylated plaster. 

PARAKERATOSIS SCUTULARIS. 

This name has been given by I 'una'' to a rare condition occurring 
in a vigorous man (first on the scalp), in which thick, somewhat 

1 i,t .rii. atlas, L892, vii., Pt. xxii. 
a v. Bebra, Intern. Atlas. 1891, v. 
[ntern. Atlas. 1890, i. 



ACANTHOSIS NIGRICANS. 473 

greasy crusts enveloped bundles of hairs, the separate filaments hav- 
ing yellowish and horny cuffs that were fused with the crust. Whit- 
ish scales and horny cylinders with a perpendicular production were 
visible over several portions of the face. Upon parts of the trunk 
were brownish spots, coin- to palm-sized, exhibiting horny cones 
which projected from the follicular orifices. The cones were covered 
with horizontally placed scales. Dark-reddish, moist, and shining 
surfaces were exposed on their removal. Closely examined, the 
horny cones after removal displayed several hairs which projected, 
one above another, from each cone, having been extruded from their 
follicles at different times. The author believes the disease to be 
allied to Devergie's pityriasis pilaris. 

ACANTHOSIS NIGRICANS.* 

(Gr., anavda, spine; Lat., niger, black.) 

(Keratosis nigricans, Fr., Dystrophie papillaire et 

PIGMENTAIRE. ) 

Pollitzer in 1890, and after him Janovsky, Unna, Darier, Spiet- 
schka, and after them many others have described under these titles 
a rare condition of the skin which it seems Crocker first reported in 
a patient. Nearly fifty cases are now on record, the most corre- 
sponding to a relatively fixed type. 

Symptoms. — The disease is one commonly strictly limited to a 
definite region of the body, often symmetrical in distribution, and in 
all instances characterized by papillary hypertrophy and pigmenta- 
tion. The regions most commonly involved are the nucha, the mam- 
mary, the ano-genital, and popliteal spaces, the axillse, the hands, 
the feet, the umbilicus, and the mouth. The color of the patches 
when fully developed is a deep blackish hue, but in some cases 
lighter shades of yellow and brown are displayed, often the pigment is 
somewhat irregularly distributed. All the pigmented areas are more 
or less thickly covered with agglomerated or discrete tubercles, papil- 
lomatous growths, or vegetating masses. In some cases these lesions 
are so small and thickly set as to produce a mamellonated effect; in 
other cases, large, broad, sessile or pedunculated tumors spring from 

bibliography: Spietschka, Archiv, 1898, p. 247; C. G. XL, 1899, p. 98. Mena- 
hem Hodara, Monatshefte, 1905, p. 629; B. J. D., 1906, 18, p. 257; J. C. D., 1905, 
23, p. 500; Annales, 1906-7, p. 82. Hodara, Un cas de Acanthosis nigricans pre- 
cede de cancer, de la mamelle, Mai. Cut., Juli, 1905; Central., 1906, No. 7, p. 213. 
P. A. Pawlof, Monatshefte, 1902, 34, 269-279; Archiv, 1903, 64, 461; B. J. D., 1902, 
xiv., p. 361. Barsky, Wratch, 1898, p. 957; C. G. TJ., 1899, p. 97. Spietschka, 
Dystrophie Papillaire et Pigmentaire (Acanthosis Nigricans), Archiv, 1898, p. 247; 
C. G. IT., 1899, p. 98. Frankenstein, Inaug. dissert., Heidelberg, 1904; Monatsh., 
1906, 42, p. 247. Hess, Munch, med. Wochensch., Bd. 50, H. 38; J. C. D., 1904, 
22, p. 533. Burmeister, Arch. f. Derm, and Syph., 1899, p. 343; C. G. TJ., 1899, 
p. 322. Grouven und Fischer, Archiv, 1904, 70, pp. 225-238; B. J. D., 1904, 16, 
p. 433. Darier, B. J. D., Jan., 1897, p. 27. Janovsky, Internat. Atlas, Selt. 
Hautkrank., Heft iv. Allen, Discussion— N. Y. D. S., Cutan., 1906, 24, p. 274. 
Menahem Hodara, Mai. Cut., 1905, No. 7, S. 502; Zeitschr., 1906, 13, p. 810. 
Kuznitzky, Archiv, 1896, Bd. xxxv., p. 3. B. Beron, Archiv, Bd. 59, 1902, p. 387. 



171 



HYPERTROPHIES. 



the pigmented patch, [n well-marked cases, the natural furrowsof the 
skin of the affected pari are exaggerated. In yei others, freckles, 
pigmented wart-, seborrheic wan-, ot pigmented nrevi are scattered 
over the affected ana. In some cases the color is deepest along the 
lines tracd bv the vein-: and the normal area- of the >kin appeared 



Fig. 




Acanthosis nigricans. (Heidingsfeld.) 

to have an unnatural lustrous shimmer. The tongue may be covered 
with prominent villous growths; a similar condition has been noted 
over the epiglottis and pharynx. Darier states thai at times the en- 
tire cutaneous surface may be involved. 

Alopecia, complete or partial, of the hairy scalp and changes in 
the nails, usually dystrophic in character, are noted. The general 
health may at first seem unimpaired. In the end, almost invariably, 
a cachexia develops of grave portent. 

Etiology. It i- now generally accepted that acanthosis nigricans 
of pure type, signifies a cancerous involvement of one or more of the 
viscera. The Liver, spleen, and other of the abdominal organs have 
been found Involved; in a few cases the cutaneous lesions themselves 
have been die origin of a malignanl epithelioma; in one instance re- 
ported, the disease hogan with carcinoma of the female breast. More 
lhan half of all the patients thus far reported have been women. In- 
fantile cases occur even as early as the second year of life: but the 
may develop also in advanced years even in the seventh de- 
cade. Our few patients have heen in early adult life. In one, the 
entire femoro-crural region was involved in a young man of twenty- 
six. Darier is inclined to the belief thai in childhood a teratoma or 
benign growth may have operated in the manner of a carcinoma of 



ACANTHOSIS NIGRICANS. 



475 



the abdominal region in later life, as an irritant of the great sym- 
pathetic, provoking thus the change in the sensitive territory. 

Pathology. — Histological examination of the tissue in acanthosis 




Acanthosis nigricans. (Heidingsfeld.) 



nigricans reveals : hyperacanthosis giving place to hyperkeratosis, 
thickening of the epiderm, with preservation of the granular layer; 
pigmentation of the palisade layer of the rete and two or three ranks 



Fig. 76. 




Acanthosis nigricans. (Heidingsfeld.) 



of cells beyond, irregularly elongated and ramifying papillae, and no 
special changes in the connective tissue of the derma or the vessels. 



476 iiYFEirrEOPHiES. 

Diagnosis. — The diagnosis lies between papillomata, Benile ver- 
seborrhoea nigricans < the superficial character of which is read- 

- follicularis, arsenical pigmenta- 
ti"ii. Addison's disease, and xeroderma pigmentosum. The distinc- 
tion between all is readily effected by consideration of the special 
charact ch disease. 

Treatment.- -The treatment i~ unsatisfactory. Boeck employed 
snpra-rena] extract in capsules. 

Prognosis. — In cases of abdominal cancer, the outlook is grave. 

CALLOSITAS. 

(Lat., callus, hard flesh.) 

(Callosity, Keratoma, Tyi.oma, Tylosis. Ger., Verhartung.) 

Callosities are acquired superficial, circumscribed, dirty-white, 
yellowish-white or darker, flattened, thickened, and horny patches of 
epidermis, dense in structure, usually insensitive, and occurring for 
the most part in regions of pressure and friction on the hands and 
feet. 

Symptoms. — Callosities vary in size from that of a finger-nail 
to that of a section of hen's egg, being at times larger; they occur 
chiefly upon parts of the integument subjected to long-continued 
intermittent pressure, as the hands and feet; also upon parts stretched 
over osseous prominences, as those over the ischia. Section of a sin- 
gle plaque shows it to be largest at the centre and least at the periph- 
ery. They are commonly encountered among mechanics, carpen- 
ters, shoemakers, etc. ; among persons wearing no coverings for the 
feet or ill-fitting shoes (heel, or ball of foot, or big toes), stockings, 
or surgical apparatus; among workers in metals, acids, or heated sub- 
Btances; and among musicians (harpers, banjo-players, etc.). They 
are so characteristic of these trades that by their location alone they 
point in many cases to the occupation of the individual who exhibits 
them ; where they are not too large they are essential to the prosecu- 
tion of such work. Inflammation may occur in the subjacent tissues 
and severe dermatitis, lymphangitis, and necrosis result; they may 
readily serve n- foci of cutaneous disease (eczema, psoriasis, etc.). 
They are produced by -ueli external causes as pressure, friction, chem- 
ical agents, and heat. They can readily be distinguished from eczem- 
atous, psoriasic, and ichthyotic patches, being always limited to the 
Bites of external contact. 

Pathology. The pathological features of callosities are: marked 
hypertrophy mid compaction of the stratum cornenni and thickening 
>>\ the Btratum granulosum, the rete mucosum on the contrary being 
thinned by the pressure. The papilla? are often flattened from the 
same cause. The corium may exhibit Bigns of inflammation when 
the callosity has been converted into a source of irritation. 

Treatment. < iallosities require treatment only when they are 
sources of pain or of discomfort. They may he removed — surgically, 



CLAWS. 477 

by the knife; chemically, by the destructive action of acids or alka- 
lies ; rationally, by disuse of the part to an extent sufficient to inter- 
fere with the operation of the cause. When painful they may be 
poulticed. A nightly soaking of the callus with warm oil, kept in 
contact with the thickened epidermis during the hours of sleep by a 
compress of flannel saturated with the same substance, will in the end 
soften the induration. Other methods of treatment advised are : the 
continuous application of a 10 to 25 per cent, salicylic plaster or mull 
(Stelwagon) ; the salicylated collodion-paint recommended for corns; 
and the scraping away of the outer layers of the epidermis with a 
dull knife after soaking in solution of lactic acid, borax, or weak potas- 
sium hydroxide solution, protecting the part afterward with zinc- 
oxide plaster. 

CLAVUS. 

(Lat., clavtis, a nail.) 

(Corn. Ft., Cor, (Eil de Perdrix; Ger., Huhnerauge, 
Leighdorn.) 

.. Corns are circumscribed, conically shaped hypertrophies of the 
horny layer of the epidermis, presenting inferiorly a prolongation, 
which, being pressed from without inward upon the sensitive papillae 
of the corium, excites pain in various degrees. 

Symptoms. — Corns vary in size from that of a pea to that of a 
large chestnut, and commonly are described as " hard " or " soft." 
The former are dense and callous, occurring upon those prominent 
parts of the foot on which the boot, shoe, or gaiter exercises its great- 
est pressure. Soft corns develop upon the lateral face of a toe in 
apposition with another, the lesion originating from pressure through 
the medium of the neighboring toes. It is softer in consequence of 
exposure to heat and moisture. Corns are often weather-sensitive, 
being unusually painful before, during, or after the occurrence of 
storms, and should not be confounded with gouty or rheumatic de- 
posits below the skin. They are seen occasionally upon the palms 
of the hands and, when occurring upon the soles of the feet, are often 
the sources of severe distress. 

The modern methods employed by the manicure and the chiropo- 
dist, often ignorant of the measures requisite to insure asepsis both in 
- their instruments and hands, are often responsible for a series of disor- 
ders which are encountered not rarely by practitioners in the larger 
towns of all countries. Suppuration beneath the conical plug form- 
ing the corn is not rare, and not only may eczema, erysipelas, and 
other inflammatory affections be excited to activity by their proce- 
dures, but even a grave lymphangitis spreading the length of the 
entire extremity may result. 

Histology. — Corns are composed of superimposed, and often con- 
centrically arranged, layers of epithelium, between which are found 
at times minute hemorrhagic extravasations. At the periphery of 



478 HYPERTROPHIES. 

the corn the corium is unchanged, but at the point where its central 
cone is pressed into the deeper structures the papillae are either 
atrophied or absent. A corn at the periphery exhibits, according to 
Unna, a thickening of the prickle- and granular layers. There is a 
central horny layer, the outermost stratum of which gives evidence 
of " welding." But the core itself which is composed, of compressed 
masses of the horny layer eonically pointed below, exhibits a flattened 
ridge-net and papillary body. Often the sweat-pores are preserved, 
and may be traced running dilated and with many windings through 
the epithelium deeply into the core. The granular layer here disap- 
pears, and the general flattening is so great that the margin between 
the horny cells and the flattened prickle-layer is lost. 

Treatment. — Corns, when rationally treated by disuse of the feet, 
or by the adjustment of properly fitted coverings for the same, will 
usually fall spontaneously. They are always shed from the feet of 
the paralyzed. They may be softened by prolonged maceration in 
\v;iicr, by poultices, or, best of all, by oil, as in the treatment of cal- 
losities. Erasion, dissection, and excision may be practiced, if de- 
manded by an exigency. Where the sufferer necessarily must con- 
tinue the use of the foot, the simplest and best treatment is as follows : 
The part is macerated thoroughly for half an hour with water as hot 
as can be tolerated. Then the projecting callous portion of the corn 
is removed by gentle cutting or scraping until, as nearly as may be, 
the surface is level with the plane of the adjacent skin. Then the 
part is dried, and the entire surface, both of the seat of the corn and 
the adjacent integument, is covered completely with many narrow, 
short, and nicely adjusted strips of rubber-plaster. Burgundy pitch 
melted and painted over the part may be applied as a substitute for 
the plaster. When the trifling operation and dressing are complete 
the patient should bear firm pressure over the corn without flinching, 
and walk with comfort. The plaster remains until it separates spon- 
taneously, which is usually in the course of a few days. The corn 
is then macerated at night with an oil-poultice, as described above, 
and the dressing afterward reapplied, usually the second time by the 
patient. Persistence in this course is followed by complete relief if 
the coverings of the feet be properly fitted. Caustics are usually un- 
necessary when there is no ulceration of the hard corn, and are in 
this situation frequent sources of great distress. They are chiefly 
valuable in the treatment of the soft variety, but they should al- 
ways be applied with a skilled hand. 

For this purpose acetic acid or the silver nitrate crayon may 
lie employed. The proprietary "corn-salves" sold in the shops com- 
monly contain the ointment of mercuric nitrate, which also in reduced 
strength is a useful application to the soft variety of corn. The 
latter should !»<• protected by the interposition of absorbent cotton 
or wool from contact with adjacent toes. 

As a rule, the ringed corn-plasters sold in the shops are inferior 
to the dressing with the rubber or salicylated plaster, made to cover 
the entire corn. 



CORNU CUTANEUM. 479 

Soft corns occasionally require pencillings with the silver-crayon 
after the outer horny layer is removed. Corns may also be removed 
by the salicylated collodion employed for warts (q. v.). 

CORNU CUTANEUM.1 

(Lat., cornu, a horn.) 

(Cutaneous Horn", Cornu Humanum. Fr., Corne de ea Peau; 
Ger., Hauthorn, Hornauswuchs.) 

Cutaneous horns are rare corneous excrescences greatly varying 
in shape and size, often resembling the similar growths in the lower 
animals. 

Symptoms. — Cylindrical, conical, straight or twisted, angular and 
otherwise irregularly shaped and sized corneous eminences, commonly 
single or more rarely multiple, occasionally project from the scalp, 
forehead, nose, lips, ears, penis, or extremities. The sites of prefer- 
ence are in the following order : the scalp, forehead, temples, nose, 
lower extremities, male genitals, and trunk. Horns are named from 
their resemblance to the similar appendages in horned cattle, but 
they widely differ from cattle-horns, which are always implanted 
upon osseous tissue. Human horns are formed of dense and massed 
columns of epithelia, often resting upon prolonged papillae. Occa- 
sionally, on section, they exhibit the concentric arrangement of the 
epithelia seen in corns, but, unlike the latter, have re-entrant basal 
depressions into which the papillae below penetrate. At times they 
are implanted in a dilated follicle, in which case the glandular ele- 
ments participate in their formation. At times, also, they represent 
a corneous transformation of the epithelia which constitute warts. 
They are seen in all colors, but are often between a yellowish brown 
and a brownish black, with fissured or wrinkled or longitudinally 
grooved exterior, like rough bark (Fig. 77). They may be painless 
or, like other keratoses, become the seat of inflammation in various 
grades. They may be short or several inches in length (Fig. 78). 
They may be shed spontaneously never to return, or may shortly 
reappear. They occasionally develop into epitheliomata. 

Brinton 2 has exhibited an anteriorly curved horn one and seven- 
eighths inches long and three-eighths of an inch in circumference, 
removed by him from the glans penis of an elderly patient. Four- 
teen cases are on record of a similar growth in this situation. In 
the horn growing from the lower lip of an elderly man exhibited in 
1886, at our clinic the growth was longitudinally furrowed, and also 
at somewhat regular intervals transversely seamed, presenting thus 
the appearance of the joints of the sugar-cane. 

Etiology.- — The cause is without question that of the senile wart 

1 For review of the subject, with bibliography, see Marcuse, Archiv, 1902, lx., 
p. 197; and Pasini, Giorn. ital., 1902, xxxvii., p. 475. 
2 J. C. D., 1887, vi., p. 272. 



480 



HYPERTROPHIES. 



for most cases; though, as with epithelioma, horns occur in infancy. 
They have been recognized as starting from a sebaceous cyst. They 
develop, if at all, more often after the fortieth year of life, though 



Fig. 78. 




Varieties of cutaneous horns. 



occurring in infancy and with slightly greater frequency in women 
than in men. 

Pathology. — Pathologically these hypertrophies are developed first 
either within a closed atheromatous cyst or from remarkably elon- 
gated papillae of the corium. They are made up of comified and 
hypertrophied epidermal cells. According to Unna, they are all 
papillary and medullated keratomata growing on a circumscribed 
warty base. The first stage of their development is characterized by 
a simultaneous acanthosis and hyperkeratosis, dense, epithelial taps 
reaching toward the corium. In the second stage of horn-formation 
the keratosis advances and the acanthosis diminishes. Sets of horny 
wedges sink downward into the epithelial taps and ridges, fill the 



VEREUCA. 



481 



spaces between the papillae, and are capped above by a horny cupola. 
Lebert shows that horns develop into epitheliomata in about 12 
per cent, of cases. As horns are really metamorphoses of epidermal 
cells similar in many features to warts, it is not surprising that the 
two often undergo the change from benign to malignant epithelial 



Fig. 79. 




Cornu cutaneum. (Heidingsfeld.) 

growths. In a few cases horns have developed to an appreciable 
degree on epitheliomata; but under the microscope this horny meta- 
morphosis on a smaller scale may be recognized in a large number of 
epitheliomata situated on the back of the hands of elderly men who 
have been farm-laborers, sewer-builders, or workers in contact with 
earth. 

Treatment.- — Horns may be removed by extirpation after soften- 
ing with alkaline dressings, after which the surface upon which they 
were implanted should be cauterized thoroughly to insure a failure 
of return. 

Prognosis.- — Tn formulating a prognosis the possibility of an epi- 
theliomatous result should not be forgotten. 



VERRUCA. 

(Lat., verruca, an excrescence.) 
(Wart. Fr., Verrtje; Ger., Warze.) 

Warts are overgrowths of clusters of papillae of the corium cov- 
ered with thickened and hypertrophied epidermis presenting them- 
selves clinically as cutaneous excrescences; congenital or developing 
after birth ; split-pea-sized to many larger dimensions ; sessile or 
pedunculated; pointed or flat; smooth, rugous, or having a cauli- 
flower appearance, pigmented in various shades of the natural color of 
the skin; soft, dense, or corneous to the touch. They may develop 
slowly or rapidly, and may persist for years or disappear without 
apparent cause. They may be single, multiple, or exceedingly num- 

31 



482 HYPERTROPHIES. 

erous; and occur upon the hands, feet, face, scalp, neck, genitals, and 
other parts of the body. They are usually discrete, but may be con- 
tinent and form palm-sized and larger elevated plaques. Fox, of 
]STew York, has reported a case in which warts occurred in the lines 
tattooed on the skin of a young man. 

The several names given to the various forms of warts have chiefly 
a descriptive value. 

Verruca Acuminata 1 {Condyloma Acuminatum,; Moist or Venereal 
Wart, Fig-wart; Ger., Spitzenwarze, Venerische Warze, Feigwarze, 
Spitzencondylom) is a filiform, papilliform, or cock' s-comb-1 ike vege- 
tation, developing usually on the mucous membranes of the genjtals. 
They are single or multiple ; at times hundreds coexist upon the 
genitalia and neighboring regions. In size they vary from that 
of a pin's point to that of a hen's egg, and may be larger. They 
are usually moist and secreting, frequently being covered with a puri- 
form mucus of exceedingly nauseating odor. The secretion at times 
desiccates so as to cover the lesion with a thin crust. The warts are 
often the seat of a very considerable pruritus. They are encountered 
upon the glans, around the frenum, and over the prepuce of men; 
and in women about the clitoris, labia, ostium vagina?, and anus. 
They are usually of a bright-red color in these situations. When oc- 
curring upon the integument they are firmer, drier, and exhibit a 
tendency to luxuriant growth. In rare cases they may be recog- 
nized about the axillary regions, the umbilicus, the interdigital spaces 
of the feet, and even the face. They may cover the side of the 
chin. 

The summit of these warts may be tufted, acuminate, or flattish ; 
on the surface of the skin, unconnected with mucous membrane, they 
may have the color of the unaltered integument. They are often 
minute and numerous as well as multiple and large ; or they may be 
single throughout, though, as a rule, they multiply when untreated. 
Their largest maximum development is observed in negroes, in 
whose persons they may attain unusual proportions. There was 
lately exhibited at our clinic a male negro with a compound venereal 
wart of the penis that was of the size of an orange. 

These warts are almost always the result of exposure of the 
sexual parts to venereal secretions (blennorrhagic, syphilitic, leucor- 
rhoeal, etc.), and, though observed in virgins, are decidedly rare in 
individuals of both sexes of that class. In pregnancy they often 
attain a large size and rapid development, but, as a rule, disappear 
when parturition is completed. They are contagious and furnish 
auto-inoculable secretions. Cocci and bacilli have been recognized 
in several varieties, thus explaining many otherwise obscure histories. 

Verruca Acquisita, — Verruca acquisita is a term used to designate 
lesions developed after birth. 

Verruca Congenita is a linear ncevus. Often first noticed several 
months after birth, they may be single or multiple, usually the latter, 

*For bibliography, see Joseph, Mr; H 's Handbuch, iii., p. 425. 



PLATE XX 




Congenital Warts. 



: e 



VEBBUCA. 483 

in which case they are arranged in lines. They are, as a rule, 
roundish, slightly pigmented, and scarcely larger than split pease. 1 

Verruca Digitata, — This is a term descriptive of the form of wart 
exhibiting finger-like prolongations separable from base to point. 
Often each separate filament is horn-capped. This type of lesion 
often occurs as a succedaneum in other affections (e. g., blastomycosis 
of the skin, syphilis cutanea capillitii, etc.). 

Verruca Filiformis.- — This variety of wart differs somewhat from 
the others, not only pathologically, as is noted below, but also in its 
clinical features. These warts are pointed growths, soft, slender, 
thread-like, often pedunculated, usually covered with a smooth and 
apparently unaltered epidermis ; they occur upon the face, neck, eye- 
lids, chest, and ears. Kaposi concludes that they are minute fibro- 
mata. 2 

Verruca Dorsi Manus et Pedis (Unna). — This is a nsevus with lesions 
symmetrically grouped upon the dorsal surfaces of the metacarpi of 
the thumb and index finger. The lesions are flat, round, or polyg- 
onal, two to six millimetres in diameter, externally presenting a 
punctate appearance, occurring in middle or later life, and exhibit- 
ing no tendency to spontaneous change. Pathologically they dis- 
close a distinctive thickening of the prickle-layer from the periphery 
to the centre. They lack many of the characteristic microscopical 
features of the ordinary seborrheic wart. 

Verruca Glabra is distinguished by its smooth surface. 

Verruca Necrogenica is a tuberculous wart, occurring on the hands 
of persons who have been in contact with tubercle-bacilli, chiefly 
as a result of handling the bodies of the dead. For details, the chap- 
ter on Tuberculosis of the skin should be consulted. 

Verruca Plana (Verruca Plana Juvenilis*) is a distinct clinical 
entity ; it is flat, smooth, and but slightly elevated. The plane warts 
may be single, but are commonly multiplej and they usually vary 
in size from that of a pinhead to that of a small split-pea, but may be 
much larger. They often are grouped, and may have a polygonal 
outline, closely simulating the papules of lichen planus. In young 
people these plane warts are usually small, multiple, often grouped; 
have the color of the normal skin or are slightly yellowish or whitish, 
occasionally bluish; and are seen most frequently on the forehead, 
on other parts of the face, and on the backs of the hands. In older 
people this form of wart shows less tendency to grouping than in 
the young, often is pigmented, and may be associated with or form 
the beginning of superficial epithelial changes. 

Verruca Senilis vel Plana (Verruca Seborrheica, Keratosis Pig- 
mentosa). — These warts are small pea- to coin-sized, and larger, 
smooth, softish growths developed upon the face, trunk, and extrem- 

1 Cf. Nsevus Pigmentosus, Nsevus Verrucosus, Nsevus Urdus Lateris, etc. 

2 See Taylor 's observations as epitomized in the chapter on Fibroma. 

3 For bibliography, see Joseph, Mracek's Handbuch, iii., p. 518. 



484 



EYPEETBOPHIES. 



ities of persons of advanced years. They are flat, usually pigmented, 
and have a granular aspect. They are readily separable by the 
finger-nail, and then are found to rest upon a reddish granular base. 
As a result of external injury (caustics, traumatism) they may 
become the starting-point of an epithelioma. 

Verruca Vulgaris is the form most frequently seen upon the fingers 
and hands, as single, multiple, or exceedingly numerous, pin-head- 
to pea-sized, usually discolored, papilliform excrescences, dense or 
softish, rapidly or slowly developed. The top of each is commonly 
grayish, yellowish, or blackish in tint. Exceptionally these warts 
develop on the borders of the lips, the scalp, the axillae, and the groins. 
Warts on the sole of the foot are not uncommon. Hardaway 1 
has directed attention to the frequency with which warty growths, 
callosities, and hyperhidrosis of the feet occur in those suffering 
from flat foot and Morton's foot and the benefit derived from ortho- 
pedic treatment. Upon the fingers an exceedingly annoying site is 
within or upon the nail-folds and beneath the free borders of the nails, 
situations often affected in several fingers of both hands, especially in 
young women. 

Fig. 80. 




Etiology. — Most warts are nests of microorganisms of different 
varieties. The precise cause, however, is unknown; but in early 
childhood, a period in which warts frequently are encountered, it is 
reasonable to conclude that they result from external contacts. It is 
when the child begins to handle everything within reach that they 
usually first appear, and then about the hands. They are probably 
l J. C. D., 1906, p. 127. 



VERRUCA. 485 

in a feeble measure both auto-inoculable and infectious. Fox, Allen, 
and Stelwagon have recognized coexistence in one subject of both 
warts and mollusca. Jadassohn inserted fragments of ordinary warts 
from four patients in superficial incisions of the epidermis in six 
different adults. Out of seventy-four inoculations, thirty-three were 
followed in from two to six months by the development of warty 
lesions. 1 Acuminate or condylomatous warts chiefly occur in parts 
moistened with a blenorrhagic secretion, but unquestionably they may 
originate from contact with leucorrhoeal or pathological, non-venereal 
discharges from the female genitals. Senile warts are more prob- 
ably due to obscure changes in the nutrition of the integument. 
The etiological importance of the cocci and bacilli which many of 
them furnish cannot be determined at this time. 

Pathology. — The verrucous process begins with downward and 
upward growth of the rete-cells, resembling in this respect benign 
epithelioma. The granular layer is remarkably thickened, while 
the greatly hypertrophied horny layer is less compact than normal 
owing to imperfect keratization of the cells, in many of which the 
nucleus is still apparent. The descending rete-processes are usually 
pointed and turn toward a common centre, producing thus a shallow 
cup-shaped depression in the cutis. 

The papillae beneath the wart are flattened, many being obliter- 
ated, except a few at the centre of the base. These hypertrophy, 
become elongated, and with their dilated vessels form a vascular 
"core" for the verruca. In the pointed forms the connective-tissue 
and vascular elements are marked, while the horny layer is but 
slightly hypertrophied. In verruca plana the chief change is in the 
rete, the horny layer being but little thicker than normal. 

The seborrhcei'c wart is characterized by a thickened horny layer 
and hypertrophied rete, with grouped and linear epithelioid cells 
separated by bundles of connective tissue in the papillary and sub- 
papillary layers. The coil-glands are fat-infiltrated, as also parts of 
the rete and cutis (Pollitzer 2 ). In verruca acuminata there is no 
tendency to cornification. The rete and papillary bodies are remark- 
ably hypertrophied and macular. 

Diagnosis. — It is a matter of importance to recognize the fact that 
many epitheliomas begin as warts ; therefore the verruca of those ad- 
vanced in years should always be examined and treated with a view 
to this fact. A tendency, especially in the aged, for the lesion to 
break down into an ulcer should arouse suspicion. Warts on the face 
and the backs of the hands of the aged are often of this class. 

Another class of warts are tuberculous in character, and, whether 
occurring in the young or the aged, are the result of infection with 
tubercle-bacilli, a generalized tuberculosis at times originating in 
these lesions (vide Tuberculosis Verrucosa). 

Great care must be had to distinguish the moist variety from 

1 Verhand. der v. deutschen. Cong., 1896, p. 497 (bibliography). 
2 B. J. D., 1890, ii., p. 199. 



486 



HYPERTROPHIES. 



syphilitic condylomata. In the latter there is usually a history of 
contagion with other syphilodermata upon the surface, such as mucous 
patches, palmar lesions, or papules of the face. Fibroma, or mollus- 
occurs in tumors of greater number, firmer 



Fig. 81. 




Vertical section of the summit of a pointed wart: a, papilla containing vascular loop; 
c, stratum corneum ; d, hypertrophied rete. (After Kaposi.) 

consistence, and larger size. The tumor of molluscum epitheliale 
greatly resembles a wart, but the waxy-whitish appearance of the 
lesion and its dark pnnctum at one plane or another sufficiently dis- 
tinguish it. In exceptional cases verruca plana may in shape and 
grouping closely simulate lichen planus, but the location and history 



VERRUCA. 487 

together with the absence of the typical color, of the varnished appear- 
ance, and of the itching, characteristic of lichen planus, will make the 
clear. 

Treatment. — Crocker, Colrat, Thin, and other writers still teach 
that there is an effective treatment of warts by the administration 
internally of magnesium sulphate in repeated doses, liquor arsenicalis, 
nitro-muriatic acid, the tincture of thuja, and thyroid extract. 
Warts may be removed by excision, erasion, or caustics (silver ni- 
trate, alkalies, acids, ferric chloride, corrosive sublimate, etc.). The 
larger growths upon the genitalia that are often highly vascular may 
demand the prior application of a ligature when they are peduncu- 
lated. Even the slender filiform warts will be found to contain a 
small vessel in each pedicle that demands cauterization after excision. 
Ordinary venereal warts require scrupulous cleanliness, deodoriza- 
tion with chlorinated soda, and afterward dusting with calomel or 
with powders of inert material (fuller's earth, lycopodium, talc) con- 
taining 10 per cent, of salicylic acid, alum, or tannin. When warts 
cannot more readily be removed by the knife or by curved scissors, 
the Paquelin cautery may be used. The blackened eschar which is 
left prevents hemorrhage, serves as the best subsequent dressing, and 
is less likely to be followed by a return of the growth. In some 
cases it is a useful expedient to transfix the lesion in several direc- 
tions with the long needles used in gynaecological practice, previously 
dipped in a 50 per cent, solution of chromic acid. 

One may also transfix the base of the wart a sufficient number of 
times with a needle connected with the negative pole of a galvanic 
battery, the positive pole being connected with the body of the patient 
by the aid of a moist sponge. 

The formula according to which are made several of the proprie- 
tary " wart-cures " sold in the shops is as follows : 

]£ Acid, salicylic, 3ss; 2| 

Cannabis Indie, extr., gr. v; [30 

Collodii., 3ss; 15 1 M. 

Sig. To be painted over the wart with a camel 's-hair brush. 

For small multiple warts Morris recommends the following : 

B Glycerin., 3jss; 61 

Acid, acetic, dil., 3ijss; 10 1 

Sulphur, praecipit., 3j; 4| M. 

For patches of warts Van Harlingen recommends cautiously at- 
tacking one part at a time with the following paste : 

^ Pulv. acid, arsenosi, gr. vj; |40 

B^laKTSarg.,} aa <,, ad 3ij ; aa ,., ad 8| M. 

Glacial acetic acid, carbolic acid, nitric acid, chromic acid, caus- 
tic potash, zinc chloride — in fact, the entire list of caustics — have 
■been successfully used in these destructive applications. 



488 HYPERTROPHIES. 

Warts may also be treated by painting once daily with a saturated 
solution of potassium bichromate in boiling water. The liquid is 
applied cold. The application is painless and leaves no scar (Louvel- 
Dulongpre). Seborrheic warts usually are treated with shampoo- 
ings and cinnabar and sulphur pastes, 1 part of the first, 20 of the 
second, and 50 of paste. In two cases in our care of numerous and 
grouped verruca plana in young adults, rubbing the lesions daily with 
Vleminekx's solution was followed by their complete disappearance in 
two weeks. 

For warts not requiring operative removal local treatment gener- 
ally answers well. Those about the genital region often disappear if 
persistently washed with a solution of tannin in alcohol, 1 drachm 
(4.) to 3 ounces (90.), after which they are dried and thoroughly 
dusted with boric acid, or salicylic acid with lycopodium, or burnt 
alum and rosin, or what is most popular, dry calomel. Alum- and 
lead-lotions may also be substituted for the tannin and alcohol, and 
for a time be kept over the parts on a compress. 

Warts are also removable in some instances by radiotherapy, using 
a soft tube, after relatively few exposures. 

Prognosis.- — Warts are benignant growths ; in childhood and in 
early adult life they need not suggest grave sequels. It is far differ- 
ent in advanced years, for, though these excrescences possess even 
then no malignant character, they are frequent precursors of epitheli- 
oma. While it may justly be urged that the early lesions in such 
cases were really epitheliomatous and not verrucous, the fact re- 
mains that many warty formations of apparently benign character do 
in advanced years, especially when irritated by frequent caustic 
applications, undergo a cancerous metamorphosis. The tuberculous 
wart also may become the source of general tuberculous infection. 

SYNOVIAL LESIONS OF THE SKIN. 

These cutaneous lesions possess importance from a diagnostic 
point of view. We have observed them in several individuals in 
whom the exact nature of the disorder had not been understood. 
They occur in the form of wart-like projections from the skin, pseudo- 
vesicles, and bullae, always over the site of bursaa connected with ten- 
dons, traversing the small articulations of the hand and foot. They 
are seen over the metatarso-phalangeal articulations ; and in the hand 
most frequently over the dorsal face of the articulation between the 
distal and adjacent phalanges of the index-finger and thumb. The 
first form is that of a roundish, corneous, pea-sized wart with a yellow- 
ish centre, of long duration, usually insensitive unless roughly handled. 
When punctured a syrupy, yellowish, or grumous fluid exudes, which 
continues to form after repeated puncture. Split-pea-sized vesicles, 
and bulla} as large as a small coin, often exceedingly painful, are also 
seen, especially upon the feet, with simply an epidermic roof-wall. 
Each lesion contains the same thickened, yellowish or whitish fluid, 



PLATE XX 




nodes. 



LINEAE NMVVS. 489 

occasionally mingled with masses like sago-grains. In every case the 
contents of the lesions are supplied by a synovial bursa beneath the 
skin, with which the lesion is either directly connected or in com- 
munication by a short sinus. The treatment requires the complete 
excision or destruction of the secreting cyst-wall. 

Sidney Jones and Makins, of St. Thomas Hospital, exhibited sev- 
eral lesions of this character to the London Pathological Society. 

N^VUS PIGMENTOSUS. 1 

(Lat., ncevus, a mask.) 
(PlGMENTARY MOLE | ]STiEVUS SpTLUS. Get., FlECKENMAL 

Linsenmal ; Fr., Tache pig-mentaire. ) 

Pigmentary moles are circumscribed accumulations of pigment in 
the skin, developing with and without other tegumentary alteration. 

These abnormal congenital pigmentations of the skin vary in 
color from a light-yellow or chocolate-brown to a blackish hue, and 
they may be single, or be multiple and very numerous. They 
vary in size from that of a pinhead to that of the palm of the hand ; 
and are either ovoid or circular in contour, or are so irregularly 
shaped as to present a fanciful resemblance to lower animals, whence 
the popular belief as to their origin in maternal impressions. They 
occur in both sexes, and in all regions of the skin, but especially upon 
the face, neck, trunk, thighs, buttocks, and external genitals. The 
term Ncevus Spilus is applied to those pigmentations which occur 
in a smooth and otherwise unaltered skin ; in later life they may be- 
come mamillated and present a growth of poorly developed hair; 
Ncevus Verrucosus, to those which are warty, soft or hard, furrowed 
or smooth, accompanied by hypertrophy of the papillae, and often 
presenting a growth of hair ; Ncevus Pilosus, to those surmounted by 
a growth of shorter or longer, stiff or downy, dark- or light-colored 
hairs. The so-called " White Moles " are similar to those described 
above, except that the pigmentation is slight or apparently wanting. 

LINEAR KffiVUS (MORROW). 2 

(NiEVus Unius Lateris, JSLevus Verrucosus, ISLevus Nervosus, 
Ichthyosis Cornea, Ichthyosis Linearis Neuropathica, 
Papilloma Neuropathicum ITnilaterale. ) 

Moles may be, when multiple, symmetrically or asymmetrically 
developed upon the surface of the body. 

In a case reported by me 3 there were multiple monolateral pig- 
mentary nsevi distributed over the left side of the trunk in the 

1 For studies of the different forms of naevi, and full bibliographies, see Moller, 
Arehiv, 1902, lxii., pp. 55 and 371; and Eiecke, ibid., 1903, lxv., p. 65. 

2 N. Y. Med. Jour., 1898, lvxii., p. 1. 

3 Chicago Med. Jour, and Exam., 1877, xxxv., p. 377. 



490 HYPERTROPHIES. 

course of the intercostal nerves, and in such a manner as strongly 
to suggest to the eye their correspondence in site with the lesions of 
zoster of the same region. T)e Amicis 1 had previously reported a 

Fig. 82. 




Naevus pilaris et pigmentosus. 

somewhat similar case. Many other cases have been recorded in 
which pigmentary and verrucous nsevi, consisting of variously sized 
and shaped lesions, were arranged in lines or streaks, usually on one 
side only of the body, and often along the course of one or more nerves. 
Selhorts 2 and Thibierge 3 have reported cases of this type in which 
involvement of sebaceous glands produced acneiform lesions. 

Etiology. — Moles occur in both sexes either as congenital lesions 
or developing later in life. In both cases they may persist without 
change or undergo degenerative transformation at a later period. 
The cause of the linear arrangement of these lesions is undetermined. 
The explanations which have been invoked are that they follow 
nerves or vessels, or the lines of skin-cleavage, the lines bounding the 
nerve-territories (Voigt), the embryonic sutures, or the metamenes of 
the body. 4 

J Lo Sperimentale, 1876. 

* B. J. D., 1896, viii., p. 419. 

* Annales, 1896, s. iii., vii., p. 1298. For full review of the subject, with bibli- 
ography, see Werner and Jadassohn, Archiv, 1895, xxxiii., p. 341; also Strasser, 
Archiv, 1903, lxxx., p. 21 (bibliography). D. W. Montgomery gives a list of 
48 titles under which linear naevus has been described, J. C. D., 1901, xix., p. 455. 

*Cf. D. W. Montgomery, loc. cit., and Balzer and Alquier, Arch. gen. de Med., 
1901, clxxxvii., p. 717. 



LINEAR NMVVS. 



491 



Nsevi seem to occur with equal frequency in the two sexes, and 
though they usually appear at birth or soon after, they are sometimes 
first seen at puberty or even later in life. It is possible that they 
may be acquired after birth, as claimed by some authors; but it is 




Naevus linearis. 



much more probable that such presumably acquired cases are in- 
stances of rapid development from minute congenital pigmentary 
moles. 

The tendency of pigmentary nsevi, after attaining full evolution, 
is to persist unchanged for a lifetime. Their increase in persons of 
tender years is occasionally characterized by a relative rapidity of 
growth. A pilary nsevus upon the cheek of an infant may extend 
over nearly double its original area in the course of two years. In 
adults an increase in the size of these growths is unusual but does 
sometimes occur. Degenerative changes are possible. In the young 
there may be spontaneous gangrene or rapid necrosis following slight 
injury of the nsevus. In older people there may be a malignant 
transformation into carcinoma or pigmented sarcoma. 



492 



HYI'EHTUOPHIES. 



Pathology. — In pigmentary moles there is an increase of pigment 
in the deeper layers of the rete cells and a deformity of the rete pegs; 
they arc dumb-bell shaped or they present other unusual forms. In 
the derma, nawus cells can ao1 always be demonstrated. 

In the warty and hairy moles, there are in addition To these find- 
ings, peculiar cells which presenl the appearance of embryonic epithe- 
lium; they an- situated in the derma and they extend downwards, 




Nevus pigmenl 



being arranged in rows. These nsevus cells have been extensively 
studied in recent years. Some believe they are epithelium and others 
that they are endothelium cells. 

In linear nsevi there is no uniform histopathology ; in some cases 
there is a hypoplasia of the glandular organs of the skin and in others 
the papillae, vessels, or prickle-cells are enlarged or imperfectly 
formed. 

Treatment. — Pigmentary moles very rarely spontaneously disap- 
pear. Their removal may be accomplished by excision, or by destruc- 
tion with caustics, with the Paquelin knife, or with the needle by 
electrolysis. The last-named method is applicable only to the smaller 
and more superficial growths of this class. Fox 1 calls attention, in 
connection with this subject, to the need of passing the needle no 
deeper than the epidermis, sufficiently deep merely to " blister the 
surface of the black spot." The electrolytic removal of hairs from 
1 Electricity in Removal of Superfluous Hairs, etc., Detroit, 1886. 



GIANT NJEVUS. 



493 



hairy moles usually results in obliteration of the lesion. Treatment 
by the use of carbon-dioxide snow and liquid air (q. v.) is often 
highly satisfactory. Radiotherapy has been employed by us in a few 
cases of pigmentary nsevi with slight improvement in one case. 



Fig. 85. 




us unius lateralis. 



Prognosis.- — Pigmentary moles, when not removed artificially, 
rarely increase in size, thus not adding to the disfigurement they 
occasion. The possibility of the metamorphosis of these lesions into 
malignant growths after the attainment of advanced years is the chief 
element of gravity. 1 

GIANT N^VUS. 



(Ichthyosis Hystbix.) 

This group includes all cases in which the nsevus affects extensive 
areas of cutaneous surface. The classical picture of this develop- 



1 Cf. Whitehead, Johns Hopkins Hosp. Bull., 1900, 
ography) ; and Whitfield, loc cit. 



p. 221 (full bibli- 



494 HTPEKTItOPHIES. 

mental defect involves the loins and upper part of the thighs, present- 
ing the appearance of swimming-drawers. The same affection may 
involve the entire trunk or any segment of the same. In rare in- 
stances the nsevus affects the entire integument excepting the palms 
of the hands or the soles of the Peel and the face ("porcupine-man"). 
Nsevua mollusciformis and lipomatodes belong to this group. The 
affected area is pigmented, hairy in some cases, and frequently harsh, 
uneven, thickened, and divided irregularly by clefts; it may resemble 
the skins of animals or reptiles. 

ICHTHYOSIS. 

(Gr., 'ix' f n, a fish.) 

(Fish-skix Disease, Xeroderma. Ger., Fischschuppenaussch- 
lag; Fr., Ichthyose; Ital., Ittiost.) 

Ichthyosis is a congenital cutaneous deformity, characterized by 
a dry, harsh, and scaling condition of the skin, associated with abnor- 
mal cornification of its external layers. 

Symptoms. — Ichthyosis Simplex (Xerosis; Xerodermia). — The 
earliest and mildest form of ichthyosis simplex is the xerodermatous 
condition. 

The sole symptoms are cutaneous. The skin of the body, in some 
regions more than others but at times universally, is to the touch dry, 
harsh, rough, and destitute of natural moisture and unguent. Closely 
inspected, the skin-surface is seen to be scaly, exfoliation being of the 
character described as furfuraceous, and often inelastic and leathery. 
In some cases the hand passed briskly over the surface of such a skin 
will cause separation of scales in a scanty shower ; in other cases the 
flakes of epidermis are attached more or less, and the clothing of the 
patient is not, as in some forms of psoriasic and pityriasic disease, 
covered with epidermal scales. In brief, here is not in progress a 
catarrh of the horny layer, as in some of the other disorders named, 
but merely an unusual keratinic transformation of the elements of 
the layer. 

The parts chiefly involved arc the extensor faces of the extremities, 
as also the hands, feet, forearms, and legs ; but all parts of the skin 
may be involved, including the scalp, face, temples, cheeks, and even 
the lips. 

The disorder is met with in all grades, from the mildest physio- 
logical dryness suggestive of so-called " goose-flesh," to that state in 
which the face only indicates an abnormal condition of the skin. In 
some cases the xerodermatous papilla? project as in keratosis pilaris. 
The color of the integument in well-marked cases is of a dirty-yellow- 
ish or dirty-brownish shade, suggesting an unwashed condition, and in 
extreme cases, usually those of older patients, the skin becomes rather 
deeply pigmented. The affection is seen in both sexes and all ages, 
being a congenital condition, the first appearance of which is indi- 



ICHTHYOSIS. 



495 



cated clearly only after variable periods of time after birth. Ked- 
haired individuals perhaps furnish the larger number of well-marked 
cases. The general health is unaffected. Before puberty the affec- 
tion in northern latitudes will often be inappreciable in summer 
and distinct in winter. As maturity is reached, however, the condi- 
tion may become permanent. 

A child affected with what appears at first to be merely xerosis 
may exhibit an extreme type of ichthyosis before puberty, while an- 

Fig. 86. 




Ichthyosis hystrix. 



other will go through life, the xerosis of his childhood remaining 
practically unchanged. 

The xerodermatous skin both of children and adults is commonly 
sensitive to irritating agents, and is often the seat, especially in 
severe winter weather, of itching, inflammation, fissures, etc. 

In a grade of ichthyosis more advanced, the scales are massed, 
forming grayish and whitish, polyhedral elevations or plaques, regu- 



496 



HYPEETROPHIES. 



larly outlined and closely set, especially upon the extremities and cer- 
tain portions of the trunk. It is the regular setting of these horny 
plates which has given the malady its familiar title, " fish-skin " dis- 
ease. The scalp in almost all cases is dry and scaly and the hairs 
like those recognized in long-standing seborrhoea sicca of the same re- 
gion. The so-called "Alligator-shin" represents an extreme condi- 
tion of cornified integument, inelastic, discolored, and transformed 
into a cuirass covered with thick plates like those of the saurian. 
Elsewhere the scaliness described above may be present, but in a more 
marked degree. Follicular keratosis is a common feature. Varia- 
tions occur, in consequence of which the plaques, bordered distinctly 
by the natural lines and furrows of the skin, are even depressed, cen- 
trally or completely, or they assume darker shades of color — viz., 
brownish and greenish-brown. 

Ichthyosis Hystrix.- — This is a term which formerly caused great 
confusion because giant nsevus was classified under this head. At 




Fig. 87. 



jOBBk 



tl 






\~-y 




Ichthyosis hystrix. vertical section; a, masses developed from the stratum corneum , 
b, cones formed by the rete ; c, hypertrophied papilla? with dilated vessels ; d, dense 
connective tissue of corium, exhibiting numerous vessels transversely divided. (After 
Kaposi.) 



the present time it is used exclusively to designate those cases of ich- 
thyosis in which there are present circumscribed patches of spinous 
excrescences. 



ICHTHYOSIS. 497 

Ichthyosis Congenita 1 ("Harlequin" Foetus, Keratosis Universalis 
Congenita). — This exceedingly rare deformity occurs as an intra- 
uterine modification of the skin of the foetus, which usually is brought 
into the world as a non-viable monstrosity. The skin is represented 
by a thick, horny cuirass, deeply furrowed and resembling plates of 
armor. Large flakes of corneous epidermis, but partially attached to 
the corium, present their broad free edges to the outer world. The 
ears, eyelids, and lips usually are wanting, being replaced by corneous 
folds suggesting in appearance the corresponding features of a 
mummy. The fingers and toes resemble talons and claws. Death 
commonly occurs in the course of a few days from inability to secure 
nutrition by the act of sucking and from imperfect development of 
other organs than the skin. Bowen 2 believes that some of these de- 
formities are due to a persistence of the epitrichial layer of the 
foetus. 

Sherwell 3 describes a case of congenital ichthyosis of unusual in- 
terest from the fact that at the time of the report the infant had lived 
to be more than five months old, and seemed to be gaining in strength 
and improving in the condition of the skin. No history of heredity 
or of a family tendency to deformities of the skin could be obtained. 

Viewing ichthyosis as thus exhibited in various manifestations, 
it is seen to be a congenital deformity rather than a disease. It may 
be partial or general, though usually the latter, with intense manifes- 
tations over the extremities, especially over the extensor aspects ; and 
relative immunity of the face, the axillae, the groins, the flexor 
aspects of the limbs, the palms and soles, the glans penis, and the pre- 
puce. The deformity is rarely visible at birth, but usually becomes 
apparent before completion of the first year of life. It is manifested 
first in the regions of election named above — i. e., over the elbows and 
the knees — and here it may for some years only be apparent in north- 
ern latitudes in winter, disappearing almost wholly in the summer sea- 
son. When maturity is reached, the deformity has been known to 
disappear temporarily under the influence of intercurrent disease 
(variola). One patient is said to have regularly cast a slough of his 
integument in the autumn. The general health usually is unim- 
paired. 

Ichthyosis is accompanied by insignificant subjective sensations. 
The skin, indeed, of these patients may be free from the eczematous 
and other complications of the less diffuse keratoses. In four ichthy- 
otic patients who were syphilitic there was a decided tendency to the 
production of lesions of the mucous surface without cutaneous efflores- 
cence. The extensor usually are implicated more than the flexor sur- 
faces of the extremities. 

Etiology. — Ichthyosis is unquestionably a congenital condition, 

1 For bibliography, see Neuman, Archiv, 1902, lxi., p. 163; and Lenglet, An- 
nates, 1903, s. iv., iv., p. 369. 

2 J. C. D., 1895, xiii., p. 485. 

3 Ibid., 1894, xii., p. 385. 
32 



498 HYPERTROPHIES. 

though its tirst manifestations are apparent only during the second 
year of life. Crocker describes an acquired case in a septuagenarian. 
h is said to be invariably hereditary, but this should be accepted 
with some reserve. One ichthyotic patient, married to his cousin, 
had by her five children free from cutaneous disease. None of his 
parents or grandparents was affected similarly. The disease occurs 
equally in both sexes, in all lands, and in persons of all social ranks. 
Ii is Liable to aggravation in cold climates and during the season of 
winter. The general vigor and development of patients thus do- 
formed are, as a rule, unimpaired. Kaposi says :" The cause appears 
to be a local anomaly of the nutrition of the skin, especially involving 
its epidermic and fatty elements." 

Thost 1 describes ichthyosis occurring in four generations. Accord- 
ing to the ascertained genealogy, the ancestor first known to have suf- 
fered from this affection had five male children who inherited it, 
while one girl and one hoy were spared. One of these affected sub- 
jects had five children, of whom three males showed the anomaly, 
while one hoy and one girl remained free. Another brother, of the 
second generation, had five male and three female children; of these, 
four boys and two girls became affected. One of the' latter (third 
generation ) bore four children, of whom three girls inherited the dis- 
ease, while the fourth, a hoy, escaped. It appeared that the affection 
always showed itself within a few weeks after birth, in the form of a 
roughness of the palmar and plantar surface. With the growth of 
the patient the condition constantly increased in severity, the epi- 
dermis shedding in large shreds, until the disease reached its max- 
imum by the fourteenth year. There was a marked disposition to 
excessive sweating, particularly in the diseased localities; the sensi- 
bility of the skin remained normal. Microscopic examination showed 
in addition to hypertrophied papillae, great development of the sweat- 
glands, with marked thickening of the ducts. Treatment failed to 
give more than partial relief. 

In the Molucca Islands and some ether isolated regions ichthyosis, 
on account, of its unusual prevalence, has been regarded as an endemic 
affection; hut instances of this kind are readily explained, without 
referring to climatic influences, by the operation of heredity and inter- 
marriages. 

Pathology. — In the mild forms Tuna describes an immediate for- 
mation of the horny layer from the rete without the intervention of 
keiatohyalin. The result is a complete cornification, the horny cells 
being homogeneous and containing no nuclear remnants. In this re- 
spect the hyperkeratosis is unusual, and contrary to the belief of many 
observers that cornification is impossible without the intervention of 
the keratohyalin of the granular layer. The rete is thinned more 
from an atrophic condition of the cells than from an actual diminu- 
tion of their number, though this does occur sometimes, so that only 
one or two layers of cells cover the papillary tips. The lymph-spaces 
'Inaug. Diss., Heidelberg, 1880; Centralbl. f. Chir., 1881, xiii., p. 154. 



ICHTHYOSIS. 499 

are also very small. The extremities of both the rete-pegs and papil- 
lae are broad and flattened and their necks narrowed, so that they 
suggest a dove-tailed appearance. The coil-glands possess a swollen 
epithelium and a widened lumen resembling their excretory ducts, 
which exhibit less functional activity. The collagenous fibres are 
thickened at the expense of elastic, fatty, and lymphatic structures, 
and there may be a chronic low grade of papillary and perifollicular 
inflammation without plasma-cells and with only a few mast-cells. 
The follicle-mouths either were dilated with a broad horny plug, or 
were closed, retaining the plug in the dilated neck. In severe forms 
is noted a proliferating rete with reappearance of the granular layer 
and a deeper dipping down of horny substance, the cutis containing 
many plasma- and mast-cells. In these severe forms there is less 
superficial exfoliation, the dryness characteristic of the mild forms is 
wanting, and the condition is readily transformed into the clinical 
crusting type known as " ichthyotic eczema." 

Ichthyosis congenita is believed by Bowen 1 to be due to a per- 
sistence of the epitrichial layer of the fetus. Wassmuth 2 has pub- 
lished the results of a study of a case of ichthyosis congenita (hyper- 
keratosis diffusa congenita). He found the changes limited almost 
entirely to the epidermis, the cutis showing only an insignificant 
chronic inflammation of low grade. As compared with normal skin, 
the papillae were much more numerous, broader and flatter, with 
greater irregularity in form and size. The layers of the rete were, 
thickened and the cells of the epithelial pegs assumed a spindle form. 
ISTearer the surface they became polygonal. A granular layer could 
be made out definitely only on the scalp. The horny layer varied in 
thickness on different portions of the body, but averaged two hundred 
times thicker than normal. The sweat-glands were greatly increased 
in number, but otherwise normal. Deformities of the sebaceous 
glands were caused sometimes by keratinization of the follicle-mouths. 
The hairs grew quite normally except for their deformed shape, 
caused by the thick and dense horny layer. 

Diagnosis. — Ichthyosis not only presents features which are so 
characteristic as to be unmistakable, but also those which can well 
nigh perfectly be portrayed in plates. In this respect it differs from a 
long list of cutaneous maladies. 3 

Whenever necessary in the establishment of a diagnosis, aid of an. 
important character can be obtained in the history of the disease and 
in recognition of the absence of the lesions and lesion-sequels ex- 
hibited in the exudative and scaling affections heretofore considered. 
The most conspicuous characteristic of ichthyosis as distinguished 
from psoriasis, lichen ruber, and pityriasis, is the absence of inflam- 
matory phenomena. 

Treatment. — The younger the patient applying for relief the 
larger are the chances of improvement and of possible recovery. Ich- 

1 J. C. D., 1895, xiii., p. 485. 

2 Beitrage zur path. Anat. und allgemein. Path., 1899, p. 19. 

3 Cf. portrait of the ichthyotic skin in Plate F of Duhring's Atlas. 



500 HYPERTROPHIES. 

thyosis hystrix of mature years is far less manageable. Internal 
treatment is valueless, though authors still recommend sulphur, thy- 
roid extract, antimony, and jaborandi. 

External treatment is directed to softening, macerating, or anoint- 
ing the skin, and, so far as practicable, to preserving it in a softer 
state. This softening is accomplished by frequent baths, alkaline, 
vaporous, or combined with the use of soap or green soap, and gener- 
ally followed by an anointing with vaselin, dilute glycerin, or lard. 
The French, after the removal of the denser layers of the horny 
plates with the aid of soft soap and water, anoint the body by friction 
with glycerolate of starch. Almond-, cod-liver, or linseed-oil, ben- 
zoated lard, lanolin, or even better, salicylated cocoanut-oil may be 
used after the bath. Stelwagon and others recommend the addition of 
resorcin to the unguents in the strength of 3 to 10 per cent. Sul- 
phur and ichthyol salves have also been praised. Only by the most 
assiduous perseverance is a desirable result obtained and permanently 
secured. In the severe hystrix varieties the most annoying projec- 
tions and rugosities may be removed by excision, by the Paquelin 
knife, or, less preferably, by the aid of caustics. 

Subcutaneous injections of ^ grain (0.016) of pilocarpine have 
been practised in ichthyosis, in order to induce sweating, with a 
view to maceration of the skin. Van Harlingen recommends the fol- 
lowing for use when the epidermis begins to shed after the application 
of soft soap: 

# Potass, iodid., 3j; 1|33 



01. pedis bubuli, 
Adipis. 



aa 5ss; aa 15 | 



Glycerin., 5j; 4| M. 

Anderson recommends the wearing of pure vulcanized India-rub- 
ber garments, a method of treatment too exhausting for all cases. 

Taking a general survey of the therapeutic management of ichthy- 
osis and its results, the course to be advised for the majority of pa- 
tients is clear. With but few exceptions, the subjects of this deform- 
ity are either entirely relieved or greatly better during hot weather 
and in moist atmospheres. Marked exceptions to this rule, how- 
ever, occur. Under these circumstances, and having regard to the 
essential fact that the deformity is lifelong in duration, patients 
should always, when practicable, select for permanent residence a cli- 
mate most conducive to the comfort of the skin. There is no step 
which the ichthyotic patient can take comparable in value with the 
selection of a suitable environment. 

Prognosis. — Having in view the facts set forth above, it will be 
clear that in no case can a favorable result be anticipated with a re- 
spect to a " cure " of the deformity. Treatment, persistent, pro- 
longed, and properly directed, in connection with suitable climatic in- 
fluences, may do much to improve the condition of the skin. 






(EDEMA NEONATOBUM. 501 

(EDEMA NEONATORUM. 1 

(Sclerodema [Soltmann] .) 

CEdema of the newborn is the same as that of adult life. It pres- 
ents special clinical features because of the undeveloped character of 
the infant's skin (Luithlen 2 ). 

It is characterized by the occurrence of an indurated tumefaction 
of the skin, most noticeable in the lower extremities of infants af- 
fected with impaired circulation. 

(Edema and sclerema of the newborn have long been confused. 
The distinction between them was first well established in 1877, when 
Parrot, under the title Athrepsie, first described with clearness the 
morbid condition now recognized as oedema neonatorum. 

Symptoms. — The disease, which is of exceedingly rare occurrence 
in America, is observed in infants prematurely brought into the 
world or at term, and of feeble vitality. Between the first and the 
third day after birth the child is found to be drowsy and difficult 
to waken, with the posterior and other parts of the thighs and legs, 
the hands, and the genital organs pallid, cold, livid, and retaining 
the impress of the finger as do cedematous tissues in general. At 
this point recovery may ensue, but in severe cases the oedema spreads 
always more markedly in the lower portions of the body, and the skin 
becomes violaceous red, deep yellowish, or dirty looking. As the dis- 
ease advances the integument becomes more and more difficult of in- 
dentation. Meanwhile the little patient becomes more drowsy, its res- 
pirations fewer, its cry weaker, and its temperature lower. Death 
may ensue from a pulmonary complication, from diarrhoea, or from 
any intercurrent disorder. Usually the child passes into a state of 
coma. When recovery ensues the oedema becomes less marked and the 
indurated skin more and more impressible. A few days, in satis- 
factorily managed cases, suffice to restore the patient to a condition 
of health. In some instances the oedema begins in other portions of 
the body than those named ; and in cases there is a marked febrile 
reaction. 

Etiology. — The recognized causes of the malady are prematurity 
of delivery, cardiac feebleness, syphilis, exposure to severe cold soon 
after birth, poor hygiene, atelectasis of the lungs, and malnutrition 
from inability to take the nipple. Blacker 3 describes a case, seem- 
ingly typical, in which there was no evident etiology. The child at 
five weeks was perfectly well and properly nourished, but still re- 
tained the hard oedema of the buttocks, thighs, part of the arms, and 
chest. The mother was always well, and the pregnancy, labor, and 
puerperium presented no unusual features. 

Pathology.- — There is ordinary oedema present. The skin is not 
the same as that of healthy infants born at term but presents the 
microscopical characteristics of a 6 to 8 months old foetus. 

1 Full bibliography for oedema neonatorum and sclerema neonatorum is given by 
Soltmann in Eulenburg's Beal-Encyclopadie, 1899. 

2 Mracek, Handbuch der Hautkrankheiten, Bd. iii., p. 201. 
3 B. J. D., 1898, x., p. 87. 



502 HYPERTifomius. 

Diagnosis. — The distinction between oedema and sclerema neona- 
torum is nol made without difficulty, the disorders greatly resembling 
each other. In sclerema the joints and particularly the jaws arc 
immobile ; the disease is Likely to be generalized ; the induration of the 
integument is greater; and there is no tendency to an oedema chiefly 
marked in dependent parts of the body, as over the lower limbs. 
The color of the skin in the two disorders may be nearly the same. 
The pitting on pressure of the swollen skin is highly characteristic of 
(edema neonatorum. Scleroderma does not occur in children before 
the close of the first year. 

Treatment.- — The treatment is that of scleroderma neonatorum. 

Prognosis. — The prognosis is grave, nearly '.'0 per cent, of the 
affected perish*; but with proper treatment recovery may occur when 
cedema is not generalized. 

SCLEREMA NEONATORUM. 1 

(Gr., nx'/r/pog, hard; vkav, new; yewau, to bring forth.) 

(Scleroderma Neonatorum : Sclerema of the Newborn. 
Ft., Sclereme des Nouveau-nes ; Athrepsie. Ger., Fett- 

SKLEREM.) 

This disease is not to he confused with oedema neonatorum, from 
which it is distinct. It was described first by Underwood in 1784, 2 
and is an affection of extreme rarity. It is a peculiar form of coagu- 
lation of the subcutaneous fat tissue accompanied by dryness of the 
skin so that very little fluid exudes when it is incised. 

Symptoms. — At birth, or between the second and the tenth day 
after, the lower limbs of the child assume a livid or whitish-yellow 
appearance, occasionally suggesting the line of wax; and they become 
of a leathery consistency. This condition spreads gradually over the 
lumbar region, the dorsum of the body, and the chest in front and 
behind, and in the course of a few days may involve the entire in- 
tegument excepting the palms, soles, and scrotum. "When pressed 
upon with the finger the skin produces the impression of half-frozen 
tissue; the face suggests a cold and rigid mask; the thighs in their 
sockets and the arms in the shoulder-joints are immobile. Usually 
there is somewhat less firmness of the abdominal integument. The 
taking of the nipple, deglutition, and even the opening of the oral 
orifice are effected only with great difficulty, and eventually become 
impossible. The respirations are shallow and imperceptible; the 
pulse in well-marked cases is imperceptible at the wrist; and the 
thermometer in the rectum is not raised to the lowest register of the 
ordinary clinical instrument. There is often no cry. 

There may be a coincident icterus; and often sprue has been ob- 
served in the mouth before the declaration of well-marked symptoms. 

1 For full discussion of the subject and bibliography, see monograph by Luith- 
Ien, Die Zellgewebsverhartungen dei Neugeborenen, Vienna, 1902; also Mraeek's 
Handbuch, Bd. iii.. \>. 193. 

2 Diseases of Children, 17S4, p. 7(i. 



TROPHEDEMA. 



503 



The congenital patients are often stillborn. The majority of sub- 
jects of the disease perish before the ninth day. Diarrhoea is usually 
present. 

Etiology. — Normal infant fat contains less fat acid than in adult 
life, hence it presents a higher coagulation point. Weakly premature 
infants have even less fat acid in the adipose tissue, except in the 
palms and soles, hence loss of water caused by diarrhoea precipitates 
coagulation of the fat tissue. The scrotum contains almost no fat. 

Pathology. — The microscopical examination of the skin shows a 
normal epidermis, the dermal bundles are pressed together and the fat 
tissue contains an abundance of fat crystals. 

Treatment. — The treatment of both oedema and sclerema neona- 
torum is by elevating the body-temperature (in an incubator, wrap- 
ping the entire body in wool, warm water-baths, etc.), and by im- 
proving the nutrition in every possible way (sterilized milk and 
stimulants by the stomach-tube, through the nose or pharynx). 




Chronic hereditary trophcedema. 

The body may also be well rubbed with warmed oil or camphorated 
alcohol. Brocq suggests friction with the warm hand from below 
upward. 

Prognosis. — The prognosis is grave; in rare instances when the 
sclerema has been partial, recovery has ensued. 



CHRONIC HEREDITARY TROPHCEDEMA. 1 

(Dysteophie (Edematettse Heeeditaiee [Meige].) 

The condition described under the above titles is a white, solid, 

indolent, and persistent oedema of the lower limbs occurring as a rule 

1 Nouvelle Iconographie cle la Salpetriere, No. 6, 1899, p. 453. (Abs. B. J. D., 
1900, xii., p. 372.) 



504 HYPEETEOPEIES. 

in different members of a family for several generations. We have 
had three typical examples of the disorder under observation and 
treatment. Its etiology is obscure and its therapy unsatisfactory. 

SCLERODERMA. 1 

(Gr., cK/i,puc, hard; Sip/ia, the skin.) 

(Hide-bouis'u Skin, Deematoscleeosis, Choeionitis, Sceeeiasis, 
Sclerema Am ltobum, Ger., Hatjtscleeem ; Fr., Scleeo- 

DEBMIE.) 

Scleroderma is a condition in which the skin is affected with a 
circumscribed or symmetrical, variously tinted induration, exhibited 
at times in spots, streaks, bands, or patches, often associated with tel- 
angiectases of the part involved. 

There are three fairly distinct variations of the process, the sym- 
metrical, circumscribed, and digital. They merge in rare instances. 

Symptoms. — Diffuse Symmetrical Scleroderma^ — The skin-symptoms 
of the disease may slowly or rapidly be evolved, and preceded by 
prodromic pains of a rheumatismal character, or by singular cu- 
taneous sensations (pricking, tingling, formication), or by muscular 
cramps, and neurotic sensations. In some instances also, there are 
vesicles, blebs, scales, local hyperidroses, or losses of sensibility in the 
skin which is about to become the seat of the disorder. 

With and without these prodromic features the skin and subcu- 
taneous tissue, chiefly of the upper portion of the body, become sym- 
metrically involved either in a gradually increasing induration or in 
an obscurely defined oedema of a firm character which at first pits 
under strong pressure with the finger, but later becomes as indurated 
and tense as hard leather. The integument is usually exceedingly 
difficult to pick up between the finger and thumb, and is shining, 
smooth, waxy, or of alabaster-like hue; in other cases it is of a dirty- 
yellowish, grayish shade. The line of demarcation between the sound 
and the affected integument is indistinct but as the disease affects the 
subcutaneous tissue as well as the skin there is often a peripheral 
extension of the indurated area underneath the healthy skin. The 
onset of the disorder may be acute, rapidly involving the body-sur- 
face, or the sclerodermatous change may be insidious in its progress, 
affecting one region only and thence slowly spreading to others, or 
being arrested after any grade of advance has been attained. This 
is the stage of infiltration, and when pronounced, it is not to be mis- 
taken for any other condition. The face may be, both to the eye and 
the finger, mask-like, immobile in features, and expressionless. The 
lips are then stiffened and opened with difficulty; the eyelids are 
similarly but much less severely involved. The back of the neck may 
be firm ; the chest, shoulders, and arms may be either immobile or 
movable with difficulty; the ribs are often bound down so firmly 
1 For complete bibliography, see Luithlen, Mracek's Handbuch, Bd. iii., p. 128. 



SCLERODERMA. 



505 



by the cuirass of leathery integument that respiration may be im- 
peded seriously. The temperature is not changed, and sweat may 
or may not be exuded over the affected areas. The abdominal sur- 
face is relatively spared. This condition may come on insidiously, 
and may require years for its complete evolution ; at other times the 
progress is rapid and the evolution is even subacute in type. Often 
the upper extremities are so involved that the fingers resemble curved 
talons ; the wrists lose their flexibility, the forearms their usefulness. 
So extreme is the helplessness of some patients that they require to 
be dressed, washed, and fed, even when able to travel with relative 
comfort. 

The lesions are accompanied at times by other subacute symp- 
toms, such as subcutaneous tubercles, eczema, erysipelas, canities, ani- 




Generalized scleroderma of long duration, with resulting ulcers. 



drosis, zoster, and acne. The mucous membrane of the mouth and 
the vulva in women may be affected often without grave changes in 
the skin adjoining. 

In the later or atrophic stage of the affection the oedematous or 
infiltrated areas undergo induration and contracture. The skin be- 
comes then more and more tightly stretched and thinned over the un- 



506 H YPE B TROPHIES. 

deriving structures, and it is no longer possible after drawing the 
finger over the surface to produce a yellowish-white tracing of its 
route thai disappears as the circulation slowly returns along the line. 
When this condition is reached, the atrophic skin becomes dry, scal- 
ing fissured, or even ulcerated; the wrinkles of the face disappear; 
the muscles waste considerably, ihu< reducing a limb several inches 



in circumference; the teeth may fall; the fingers permanently be 
Hexed into the palm or the forearm on the arm. When the condition 
becomes to this extent grave, the patient, who before seemed to enjoy 
a fair degree of health, suddenly experiences rheumatoid pains and 
neuralgias, or exhibits other sig-ns of constitutional impairment : and 
intercurrent visceral disorders gradually bring on a marasmus which 
in some of the reported cases has ended with renal, cardiac, or pul- 
monary symptoms. 

Circumscribed Scleroderma; Morphoea (Gr., /-"VY 1 /? a blotch); Ke- 
loid (of Addison). — Circumscribed scleroderma, or morphoea, is 
characterized by the occurrence of one or of several discrete, well- 
do I mod, firm, and smooth points, patches, lines, or bands, that are 
often slightly elevated or depressed, and surrounded by a delicate 
violaceous or lilac-tinted halo, the involution of which may be fol- 
lowed by macular, punctate, or striate atrophy of the skin. 

This form of scleroderma was once held to be rare. It is, how- 
ever, more commonly under observation than is usually believed. 
French authors distinguish between the variety displayed in plaques 
and that occurring in bands. Some forms of the latter variety are 
better described as liiieie atrophica 1 . 

Patches of morphoea commonly begin as rosy or violaceous mac- 
ules, which irregularly extend in area from finger-nail-sized to larger 
patches, either with relative rapidity or with slowness. In a variable 
period of time the centre of each patch becomes whitish, while the 
peripheral portions of the plaque retain their peculiar shade of color. 



SCLERODERMA. 



507 



There is thus formed a roundish or oval or irregularly outlined area, 
rarely larger than a dinner-plate, with a central portion slightly deep- 
ened or somewhat elevated, infiltrated and " lardaceous," or nattish, 
and near the level of the adjacent skin. The blanched centre has 
often the hue of old ivory ; later, this may be commingled irregularly 
with a flattened streak or band, distinguished with difficulty from 
scar-tissue. These patches may be single or multiple; in the latter 
event they are arranged, as a rule, along the line of distribution of the 
cutaneous nerves of the trunk, along the inner faces of the thigh, more 
often on the lower than over the upper extremities, and asymmetrical 
in most cases. When the tissue is pinched between the thumb and 
finger it at first gives the impression of stiffness and hardness ; in the 
later stages of the disease the skin may be so atrophied over the 
region involved that it is impossible to make this test. The surface 
is dry and smooth, or, when very carefully inspected, is seen to be 
traversed by exceedingly delicate lines. In some instances the plaque 
is dotted regularly with depressed points resembling the patulous ori- 
fices of sebaceous glands of the face in certain cases of acne, the 

Fig. 91. 




Morphoea guttaU 



slightly discolored, minute, funnel-shaped orifices contrasting thus 
with the dead-white hue of the patch. In other cases this appearance 
of dotting or picking out of the surface is more conspicuous at one 
part than another, being, for example, well shown at an advancing 
border, with a dead-white, depressed centre, or at both extremities 
of a long; oval. 



508 HYPERTROPHIES. 

The border of typical patches is characteristic. It is made up 
usually of a narrow zone having a pinkish, lilac-tinted, or violaceous 
hue, which, when closely viewed, is seen to be constituted of a plexus 
of fine vessels. The zone may be wanting wholly, as is well shown 
in -Mine cases in which the temple is involved; the border further 
may be present in such degree as to be fully as conspicuous as the 
whitish central area. In a patient presenting a palm-sized patch 
over the sacrum, together with a few multiple spots on the side of the 
neck (a portrait of the same having been made in oil), the flame-like, 
violet-shaded areola extended for several inches on one side away 
from the disk, and one of the larger vessels of which it was constituted 
could be seen at a distance of several feet from the patient. Purplish 
and even blackish hues have at times been recognized in the halo by 
other observers. 

As a rule, there are few subjective phenomena; in some cases itch- 
ing, tingling, pricking, and other sensations are experienced. The 
variations observed in this affection are as numerous as they are 
striking. In some cases the patches closely resemble scars ; in others 
there is marked pigmentation, diffuse or circumscribed ; in yet others 
the capillaries traversing the patch constitute a distinct network of 
predominant symptoms; in still other cases, usually of long continu- 
ance the surface of an entire limb may be converted into tissue pres- 
enting a dull-reddish area in which new vessel-formation and sclerotic 
integument are distributed equally. The disease may be extensive 
or be limited to one or a few small spots. The names: Maculosa, 
Nigra, Lardacea, Alba, Plana, Atrophica, etc., are merely descriptive 
of clinical features, and are becoming obsolete. 

Between the several types of scleroderma noted above are to be 
found instances which it is difficult to assign to the one class or the 
other. Some are mixed forms in which diffuse scleroderma is de- 
veloped in one part of the body and a circumscribed form in another; 
in other cases numerous morphoea plaques are distributed symmetri- 
cally over the body or develop a generalized symmetrical scleroderma. 
As a rule, the symmetrical forms occur most extensively over the 
upper part of the body ; while the more frequent unilateral plaques of 
morphoea affect in greater proportion the lower limbs. Often the 
symptoms of the disease resemble at the outset those described as char- 
acteristic of oedema neonatorum, with pitting of an cedematous surface 
under pressure. Great variation has been noted as regards the pres- 
ence, absence, or increase of sensibility. Sweat and sebum may or 
may not be secreted from the affected patches. 

The course of the disease is usually chronic. Many patches after 
reaching an average degree of extension advance no further. In yet 
other cases the progress continues through life, or the serious phases 
of diffuse scleroderma in advanced grade are exhibited. 

The sites of election of the disease are the face, the sides of the 
neck, the chest, the abdomen, and the extremities, though any region 
of the body-surface may be involved. Multiple patches may be dis- 



SCLERODERMA. 509 

posed symmetrically or asymmetrically in different regions, and on 
different sides of the body. 

In the generalized forms, whether symmetrical or not, there may 
occur serious complications from visceral disease (cardiac, vascular, 
or renal) due in part to interference -with the function of large areas 
of the skin. Arthritis is not infrequently a concurrent disorder. In 
some cases the mucous surfaces are involved. In other cases there are 
organic changes in the viscera as well as sympathetic disturbances of 
function. Some of the visceral muscles have been recognized as in- 
volved in scleroderma. 

According to Besnier and Doyon, pigmentation is one of the most 
important of sclerodermatous symptoms. Beside the pigmented dots 
visible over the sclerosed patches, there often exists a species of chlo- 
asma in the form of bronzing, diffuse or in irregular islets, over the 
neck, shoulders, and elsewhere. These pigmentations are often in- 
terspersed with whitish patches of vitiligo. 

The course of circumscribed scleroderma is either chronic, lasting 
for from one to ten years or more; or subacute, with evolution ac- 
complished in a few days and an almost equally rapid involution; or 
atrophy of skin, subcutaneous tissue, and muscle may slowly or 
rapidly follow, and result in the production of attachments to perios- 
teum or in deformity due to contracture. Ulceration may ensue, and 
in a few instances has occurred early in the disease. Atrophy of 
bone is an exceptional result. In yet other cases absorption of the 
material constituting the plaque is effected without sequels of any 
sort, few, if any, traces of the process remaining. 

The band-form of circumscribed scleroderma usually occurs in 
ribbon-shaped elongations stretching along a limb in its longitudinal 
axis, or over one-half of the face. Most of these cases are distin- 
guished by the occurrence of either an elevated ridge or furrow, or 
(what is not very rare) an elevated ridge with a furrow on one side. 
The median line of the forehead is the commoner site of this anomaly 
on the face; over the trunk it is best displayed on the chest. As 
noted above, some of the cases collated in this category are instances 
of linese atrophicse. 

The affection only recently known as White Spot Disease (Mor- 
phea Guttata) was first described as a clinical entity by West- 
burg; 1 subsequently cases were reported by Johnson and Sherwell, 2 
McCleod, and others. 3 In all ten cases have been observed. Johnson 
pointed out a case presented by Montgomery before the American 
Dermatological Association at its meeting in Chicago in 1901, as an 
example of this dermatosis. Subsequent observation demonstrated 
that it was a case of morphoea. The histology and similarity in 
clinical manifestations convince us that all the cases of this group 
constitute a peculiar clinical form of morphcea. 

1 Monatsh., 1901, xxxiii., p. 355. 

2 J. C. D., 1903, xxi., p. 302. 

3 Ibid., 1907, p. 1. 



510 EYPEBTROPHIE8. 

The eruption occurs mostly on the anterior surface of the chest, 
and on the neck and shoulders. The most striking feature of the 
eruption La the color or rather absence of color. The plaque is chalk- 
white or snow-white. The lesions are split-pea sized, they may 
exhibit peripheral extension clearing in the center and attain 
the size of a dollar. Coalescence of lesions may occur. These 
patches are irregular in outline and frequently show at the margin 
slightly projecting points or ridges suggesting those seen in keloid. 
Linear arrangemeul also occurs. The smallest lesions are pin-head 
sized. The largesl lesions are covered with a dry glistening epithelium 
which wrinkles readily like atrophic scar-tissue. To the eye and in 
the photograph the lesions appear elevated, but on palpation the eleva- 
tion is found to be slight or absent. The lesions are sharply defined 
and a few of them are bounded by a narrow faint hyperaemic zone. 
Continued observation shows that the lesions undergo a distinct 
atrophy, the epidermis is thin, parchment-like, and slightly depressed. 
There are uo subjective symptoms. The tactile sense is absent over 
affected areas, plaques of typical morphoea may be present in dis- 
tind locations. 

Sclerodactylia. — This is a special form of scleroderma affecting the 
extremities, especially the feet. The disease is apt to begin in child- 
hood and progress steadily but slowly through life. Tt affects the 
tips of the Toes and fingers at first, and gradually extends upward, 
involving finally the entire toes and fingers, feet and hands, ankles 
and wrists, legs and forearms, or it may affect only the lower or upper 
extremities symmetrically. The affected skin is rightly bound down 
to the subjacent structures so that it can not be drawn into folds, 
ami it presents a reddish, shiny, glazed appearance. The stiffness 
of the skin interferes with the motion of joints to such a degree as to 
render the affected parts useless. Finally ulcers form on the ends of 
the digits; they persist and sometimes they become epitheliomatous. 
Amputation of digits is necessary in some cases. Occasionally dis- 
tant areas of scleroderma are present. 

Hemiatrophia Facialis. — Severe grades of the disease are noted by 
Beveral authors, in which to a varying extent, the surface of the lateral 
half of the face has been involved. Here not only the subcutaneous 
tiesue, but also the aponeuroses, periosteum, and bones may partici- 
pate in the atrophy, a fact well illustrated in the case of Robinson's 
patient.' In this instance there was also a distinct sclerodermatous 
lesion on the face of one thigh. 

Etiology. — About three-fourths of all cases occur in women. 
The young and middle-aged are generally the victims of the disorder, 
though cases are reported not only in the first year of life but in 
advanced years. The predisposing causes of the affection are: rheu- 
matism and the climatic changes to which rheumatism is most often 
1 Amer. Jour. Med. Sci., 1878, lxxvi., p. 437. 



SCLERODERMA. 511 

attributed ; all neurotic states due to emotional influences, grief, 
anxiety, etc. ; traumatisms by friction, blows, and direct injuries of 
nerves ; blisters ; exposures to the direct action of the sun ; and obscure 
disturbances of the nervous centre that are difficult to appreciate. In 
one case, a young woman with a series of circumscribed patches along 
the inner face of the right thigh, could scarcely endure the fatigue of 
exposure of the part while an oil painting was made of the disks; 
another case was that of a muscular blacksmith, who exhibited a 
large plaque of morphoea over the trunk. Scleroderma has occurred 
as a complication of Graves' disease, and in association with Ray- 
naud's disease, lepra, Addison's disease, and other morbid states. 

The possibility that in some cases syphilis may be responsible for 
the vascular obliteration that obtains in scleroderma, has been sug- 
gested by several observers, nor are therapeutic results lacking for 
the establishment of such an etiological factor. 1 

The etiological importance of the nervous system is too obvious 
to require demonstration. This fact is much more distinct in the 
localized manifestations of the disorder, in which a region supplied 
by a single nerve or traversed by a nervous trunk is solely involved. 
Harley, Schwimmer, and others have recognized cardiac and gastric 
disturbances ; "Westphal and Eulenberg, central and peripheral changes 
in the nervous system; Heller demonstrated in one case closure of 
the thoracic duct. Bancroft 2 repeatedly recognized filarial in large 
numbers in the blood of a young girl in Australia who was affected 
with a characteristic scleroderma. Atrophy and other changes in 
the thyroid gland have been noted by Hektoen, 3 James, 4 Uhlenhuth, 3 
and others. 

Pathology. 6 — The confusion which has existed in relation to the 
question of the identity of scleroderma and morphoea is due to various 
causes. By several authors similar symptoms are described under 
each of the two names ; and the symptoms detailed as peculiar to 
each are occasionally seen either simultaneously or successively in 
the same individual. 

Microscopical examination of the structures involved in the dis- 
ease has proved unsatisfactory. The connective tissue of the skin 
has been found, according to Kaposi, indurated and thickened ; its 
elastic fibres multiplied at the expense of the panniculus adiposus; 
its muscular tissue hypertrophied ; the pigment in the rete and corium 
increased; the sweat-glands dilated; the lumen of the blood-vessels 
diminished, and their walls ensheathed in accumulations of what he 
terms " lymphatic cells." 

x Cf. Whitehouse: Paper on this subject presented to the Amer. Derm. Assn., 
June 3, 1909. 

2 Lancet, 1886, i., p. 380. 

3 Centralbl. f . allgem. Path. u. Anat., 1897, viii., p. 673. 
* Scottish Med. and Surg. Jour., 1899. 

5 Berlin, klin. Wchnschrft., 1899, xxxvi., p. 207. 

6 For a histological study of the circumscribed forms, with bibliography, see 
Zarubin, Archiv, 1901, xiii., p. 188. 



512 HYPERTROPHIES. 

The nature of the pathological process in scleroderma is un- 
known ; no characteristic changes in the nervous centres have yet 
been appreciated. In the generalized form the two vascular systems, 
the sanguine and the lymphatic, exhibit within and about the walls of 
vessels embryonic cells which become converted into fibro-plastic 
bodies. This change produces in parts an increase in the tunica 
media until it is twice its normal thickness. The lumen of the 
vessels is thus obstructed and at times obliterated, indicating that the 
essential process is an endarteritis obliterans, inducing, in the areas 
to which each twig of vessels is distributed, an exsanguinated state 
with a surrounding hyperemia. The latter accounts for the peri- 
pheral halo of the circumscribed forms of the malady. That there 
is at the same time lymphatic obstruction is clear, with, either from 
the one cause or the other, an overproduction of connective tissue and 
elastic fibres in the areas of involvement. The corium is commonly 
hypertrophied, at least in the papillary layer; while the subcutaneous 
tissue and panniculus adiposus are proportionately thinned ; and even 
at times, as suggested by the clinical features noted above, may wholly 
disappear. The pigment commonly vanishes from the prickle-layer; 
the coil glands at first are dilated, and later may disappear when the 
atrophic stage is reached. In the late circumscribed forms the papil- 
lae of the corium may also fall into atrophy, and the superior vascu- 
lar plexus of the corium may undergo obliteration by thrombosis 
(Crocker). The compression of both glands and vessels is sup- 
posed to account for the final sclerotic and cicatriform condition of the 
advanced cases. 

Diagnosis. — In vitiligo there is an entire absence of all struc- 
tural cutaneous changes and the skin has a characteristic milky- 
white color, the hairs of the part being also blanched. Both the 
pigmented macules and atrophic patches of lepra are remarkable for 
their anaesthetic or hyperaesthetic symptoms, and their coincidence 
with, or sequence from, other readily recognized symptoms of the 
disease, such as tubercles, bullae, ulcers, and involvement of the hairs, 
nails, eyes, and other organs. 

In sclerema and oedema neonatorum the age of the patient would 
serve to distinguish the disorders from scleroderma. In cancer en 
cuirassc (papillary cutaneous carcinoma), chiefly of the skin of the 
breast in women, but encountered elsewhere, the resemblance to 
scleroderma is striking; and eminent surgeons have confounded the 
two. In both affections the skin, especially that of the thorax, is 
converted into a dense leathery cuirass, but the distinction is made 
as follows: first, the carcinomatous condition of the skin may be 
secondary to a cancerous change in the breast or nipple, in which 
case the doubt is readily removed ; second, if primary, the firm, iso- 
lated, and deeply tinted nodules of cancer are readily distinguished, 
projecting from the dense peripheral cutaneous infiltration; third, 
the oedema and lymphangitis associated with cancerous involvement 
are most often unilateral, and are limited very distinctly to the arm 



SCLERODERMA. 513 

on the side of the body most seriously involved ; fourth, the line of 
demarcation of the cancerous change, while indeterminate on one 
side, is usually at the edge of advance distinguishable by tongue-like 
erythematous prolongations of a dull-reddish hue ; lastly, the tendency 
to ulceration, the coincident and resulting cachexia, the possible axil- 
lary adenopathy, and the relatively rapid and fatal result in cases at 
all liable to be confused with scleroderma, point severally to thei 
truth. 

In ichthyosis the congenital history, the presence of ichthyotic 
plates over the affected surface, and the general conservation of the 
health of the patient suffice to identify the disease. 

In progressive lenticular melanoderma (angioma pigmentosum et 
atrophicum) the melanotic condition of the skin, in connection with 
warts, tumors, ulcers, and limitations of the disease to the exposed 
parts, suffice to distinguish its character. 

Treatment. — In the management of symmetrical or generalized 
scleroderma the influence of climate should be considered. More im- 
provement is secured for these patients after removal to a dry equable 
climate than can be obtained elsewhere. If they must remain under 
unfavorable climatic influences, the body should be well protected 
by woollen, over muslin, silk, lisle-thread, or balbriggan undergar- 
ments; and while an outdoor life is desirable, such exposure should 
always be avoided in unfavorable weather. Internally cod-liver oil, 
the ferruginous tonics, and the nutrients generally are often indi- 
cated, as well as a roborant and generous diet. Thyroid extract has 
given good results in a small percentage of the cases in which it 
has been tried. Phillipson 1 reports relief of severe diffuse sclero- 
derma by the internal administration of salol in doses of from 2 to 3 
grammes daily. Hebra 2 reports good results in three cases from 
intramuscular injections every second day of 10 minims of a 15 
per cent, alcoholic solution of thiosinamin. The employment of 
potassium iodide, arsenic, mercury, and other remedies, such as lith- 
ium benzoate, sodium bicarbonate and salicylate, and the alkalies, sup- 
posed to be indicated by the rheumatoid symptoms, have been alike 
praised and condemned by men of eminence on both sides of the 
Atlantic. Remedies of the reconstituent order should always first be 
employed and no resort be had to others save in . emergency. 

The local treatment is by baths, massage, galvanism, alternate 
hot and cold douches, or the actual cautery over the spinal column. 
Following the daily salt-and-water or alkaline bath of a temperature 
suited to the season of the year and the physical condition of the 
patient, inunctions with cod-liver oil, lanolin, lard, or vaselin, neat's- 
foot oil slightly scented, or other simple oil or ointment, may be used. 
To these may be added with advantage in many cases 2 to 10 per cent, 
of the oleate of mercury or of ammoniated mercury or salicylic acid. 
In morphoea Brocq employs electrolytic puncture as in the treatment 

1 Deutsch. med. Woch., 1897, 33. 
3 Archiv, 1899, xlviii, No. 1. 



514 HYPERTROPHIES. 

of hypertrichosis. Mercurial plasters are applied in the intervals of 
each sitting. We have employed radiotherapy in circumscribed 
scleroderma without satisfactory results. 

Prognosis. — Symmetrica] diffuse scleroderma, well treated in 
young subjects, usually results favorably without impairment of the 
general health. When atrophic changes occur the skin may recover 
its suppleness and pliability, but this cannot be assured. Deformity 
in either event may complicate an otherwise favorable issue. In a 
proportion of cases the disease becomes so extensive and severe as to 
produce a fatal marasmus ; more frequently death results from inter- 
current disorders. 

In circumscribed patches (morphcea) the majority recover with- 
out serious consequences ; the few go on to sclerosis of subcutaneous 
structures and consequent deformity. In the most of the simpler cases 
the disease from first to last seems to have but a local significance. 

ACROMEGALY. 1 

(Gr., aKpoQ, extremity; fiey&li?, great.) 

Acromegaly is a disorder involving several organs of the body and 
incidentally the skin. 

Symptoms. — Transitory swellings due to vaso-motor changes 
affecting the face and hands often precede for some time the classical 
manifestations of the disorder, which include cephalalgia, rachialgia, 
and paresthetic symptoms suggesting hysteria. These are followed 
by characteristic thickenings of the bones of the hands and the feet, 
spreading at times to the foot and the leg, and involving also the 
face, especially the under jaw. In well-marked cases the under 
incisors project beyond the line of the teeth; the maxillary, malar, 
and occipital bones are thickened; the nose becomes long and broad; 
and the under lip, ears, tongue, and larynx, are deformed by thick- 
en ina'. The fingers are large, blunt-pointed ("drum-stick deform- 
ity"), and tipped with nails that appear smaller than normal in 
comparison with the bulbous digits. The so-called " hexagonal face " 
is thus produced. In connection with these symptoms there may be 
interference with articulation due to thickening of the tongue, a 
rough sound to the voice (from laryngeal changes), motor disturb- 
ances, and exophthalmos. 

The skin and mucous membranes are often the seat of changes. 
In the skin there may be pigmentation, sclerosis, hyperidrosis (often 
coincident with polyuria), hypertrichosis, and the formation of ke- 
loid at points of trivial traumatisms. The nails are thickened, 
flattened, and grooved. The subcutaneous fat often is increased. At 

1 For bibliography, see Marie, Kev. de Med., 1886, vi., p. 297; Marie and Mari- 
nesco, Trans. Derm. Cong., Berlin, 1890; Souza-Leite, De 1 'Acromegalic, Paris, 
1890 (abstr. of 49 cases) ; Collins, Jour. Nervous and Mental Dis., 1893, xx., p. 48 
(bibliography); Arnold, Virchow's Archiv. 1894, cxxxv., p. 1 (with list of cases 
published since 1890). Shallcross, Phil. Med. Jour., 1901, vii., p. 771; and Kuh, 
Jour. Amer. Med. Assoc, 1902, xxxviii., p. 295 (full bibliography). 



MYXCEDEMA. 515 

times there is an almost characteristic engorgement of the skin of the 
cheeks, which taken together with the altered contour of the face 
described above, furnishes a classical picture. 

MYXCEDEMA. 

(Gr., //if a, humor; oldew, to swell.) 

(Cretinoid (Edema, Cachexia Strumipriva, Cachexia Thy- 
roidea. Fr., Cachexie pachydermique.) 

This disorder was first described by Sir William Gull 1 in 1873 ; 
and it has since been studied, both abroad and in this country, by 
many observers. 

A complete description of the disease and a resume of literature 
are found in the report of the Clinical Society of London for 1888, 
and in Murray's elaborate contribution to the same subject, in the 
Twentieth Century Practice of Medicine, vol. iv., 1895. The report 
embodies the results of the researches of a committee — including 
Ord, Horsley, and others — specially appointed by the Society to 
investigate the subject. 

Symptoms. — The disease occurs in both acute and chronic mani- 
festations, usually after the fortieth year, and in women more often 
than in men. It may, however, first be noticed in childhood. 

At the outset there is observed a gradually occurring persistent 
and remediless ansemia, succeeded in turn by mental hebetude, slug- 
gishness of body-movements, and a characteristic change in the integu- 
ment. The skin becomes dry, rough, yellowish, waxy, translucent, 
and firm, and refuses to pit on moderate pressure. The surface in- 
volved is commonly the seat of a fine furfuraceous desquamation, the 
mucous membranes often participating in the morbid process. In 
the cheeks there is usually perceptible a brawny redness ; defined at 
times as a sharply circumscribed, pinkish flush, due to distention of 
the minute capillaries, extending quite to the lower eyelids, which 
may, as in Ball's cases, be wrinkled, boggy, and swollen. The eyes, 
for this reason, seem smaller than natural and more widely separated. 
In consequence of the swelling and immobility of the features the 
f acies is characteristic : the broad, thick nose ; swollen, pendulous, or 
even everted lips ; expressionless eyes ; and leathery cheeks, producing 
upon the observer the impression of a mask. The skin of the other 
regions of the body participates in these changes, the backs of the 
hands, for example, becoming wrinkled or distended, the palms dry 
and fissured, the feet participating in the same morbid process, the 
hair falling in nearly 90 per cent, of cases even to the production 
of extreme baldness, the nails becoming discolored, grooved, and 
cracked, and the teeth often carious, fragile, or wholly lost. The 

1 Trans. Clin. Soc, London, 1874, vii., p. 170. See, also Hun, Amer. Jour. 
Med. Sci., 1888, p. 196 (notes on 150 cases in literature), and later reports by 
Adami, Trans. Fourth Cong. Amer. Phys. and Surg., 1897 (review of subject and 
bibliography) , and Murray, Lancet, 1899, i., pp. 667 and 747. 



5 1 6 HYPERTROPHIES. 

mucous membrane of the mouth (gums, palate, pharynx) becomes 

tumid and fungous. 

In the triangles at the side of the neck, and also at its back, are 
" bolsters " of fat. The hair of the head becomes harsh and scanty ; 
alopecia may be complete. Pigment-alterations readily occur; moles 
increase in size ; and the general tint of the skin may vary from that 
of dry parchment to the hue of Addison's disease. The gait is wad- 
dling and uncertain. The thyroid gland atrophies. Anaesthesia is 
of common occurrence. The tongue, uvula, and fauces are often so 
thickened and immobile as to make speech slow and indistinct. The 
temperature is usually subnormal, the mental faculties seriously im- 
paired, the sight and hearing altered, digestion vitiated, and the mus- 
cular strength greatly reduced. 

The course of the disease is chronic, lasting for years, and termin- 
ating usually in a state of marasmus with fatal issue. 

Etiology. — The cause of myxoedema is imperfectly understood, 
though its association with abolition of the thyroid gland (after patho- 
logical change or ablation) is generally admitted. Stokes reports ten 
cases of acute myxoedema following thyroidectomy. In these cases, 
beside the rapid occurrence of the symptoms enumerated above, there 
were convulsive seizures of an epileptiform character. Of four hun- 
dred and eight complete thyroidectomies analyzed in the Clinical 
Society's report, in sixty-nine myxoedema developed. The result did 
not occur when a part of the gland was left. The influence of hered- 
ity is distinctly shown in cases reported by Ball, Ord, Saville, and 
Taylor. The disease affects women more often than men, in the pro- 
portion of seven to one. Children are attacked, but the malady is 
more common in individuals between thirty-five and fifty years of age. 

It is undetermined what relations, etiological or other, subsist be- 
tween the members of an interesting group of maladies, all character- 
ized by cutaneous changes or dystrophy of the appendages of the skin, 
and total or partial abolition of the functions of the thyroid gland. 
In this group are to be named not merely myxoedema, but also myxoe- 
dematous cretinism and Graves's disease. These maladies are de- 
nominated by some authors the "thyroid cachexias." 

Pathology. — In nearly all eases examined the thyroid gland is 
found to be markedly reduced in size and its glandular structure 
seriously impaired by substitution of fibrous connective tissue for the 
epithelial cells lining its secreting acini. At first there is a small 
round-cell proliferation, which gives place to changes resulting even- 
tually in a firm thickening of both the gland and its capsule. The 
lumen of the arteries becomes obstructed; and, in cases, new-formed 
lymphatic tissue is found surrounding the atrophied lobules. 

Examination of affected regions of the skin discloses slight epider- 
mal atrophy, replacement of connective-tissue trabecule with fine 
nucleated fibrillar, a small-cell infiltration in the upper part of the 
corium, and an endarteritis obliterans similar to that recognized in the 
thyroid gland. The epithelium of the coil- and sebaceous glands is 



MYXOSDEMA. 517 

the seat of swelling and proliferation, which eventually produces 
occlusion of the lumen of these emunctories and explains largely the 
cutaneous symptoms of the malady. The hair-follicles and the nerves 
(fibrosis of hair-pouch, perineuritis) may or may not be invaded by 
a similar process. 

Diagnosis. — Cases of myxcedema are readily distinguished from 
those of elephantiasis by the generalization of the symptoms, the 
nervous state of the patient, the fat-deposits, and the condition of the 
thyroid gland. Acromegaly involves the bones; in lepra there are 
commonly anaesthetic symptoms or characteristic tubercles. 

Treatment. — The treatment of myxoedema has hitherto aimed at 
amelioration of the symptoms by the employment of roborant and 
tonic measures ; alkaline and sulphur baths ; electricity and massage. 
The later method of treatment, however, is by thyroid-grafting, by 
administration of thyroids, and by hypodermatic injection of from 
5 to 15 minims of liquid extract. 1 Whether there be employed the 
gland itself of the sheep, the liquid extract, or the powder skillfully 
prepared by evaporation, the results are satisfactory in so large a pro- 
portion of cases that the prognosis of this group of disorders presents 
no longer an element of gravity. The headache, faintness, loss of 
weight, neuralgias, and even albuminuria, with other symptoms im- 
mediately following the employment of the thyroids named above, 
do not seem to have an adverse influence upon the remoter benefits 
received from the treatment. 

1 C/. "Feeding Thyroids in Myxoedema," by J. J. Putnam, Amer. Jour. Med. 
Sci., August, 1893. 



CLASS IV. 
ATROPHIES. 

ATROPHIA CUTIS. 

(Gr., a, privative, and r^fj, nutrition.) 
ATROPHIA SENILISM 

(Senile Atrophy of the Skin, Atrophoderma Senile.) 

This is the frequently recognized cutaneous degeneration peculiar 
to old age. The skin becomes colored in various shades of brown, 
either uniformly or in tolerably distinct pea- to bean-sized macula- 
tions over the face, the dorsum of the hands, the genitalia and the 
anus, and the lower extremities. 

Symptoms. — The skin assumes a dull-yellowish hue, is seamed 
with furrows and wrinkles, is dry and inelastic, may desquamate 
slightly, and, losing the cushion of fat upon which it rested in earlier 
life, is either readily raised from the subcutaneous structures or de- 
pends from them in loose folds. The hairs on the affected areas may 
fall or may undergo regressive changes to the lanugo-type. Pea- to 
finger-nail-sized verruciform, dirty-yellowish accumulations of sebum 
and epidermis become visible, often in numbers on the face and else- 
where, softish and readily scraped from the surface or firmly adherent 
and scaly, or there may be small pendulous shrivelled pouches repre- 
senting fibromata that have disappeared. These epithelial growths, 
especially when irritated, are not infrequently the beginning of malig- 
nant epithelioma. Occasionally they are commingled with whitish 
and grayish maculations or pin-head-sized and larger telangiectases. 

In quantitative senile atrophy the pathological changes include : a 
general thinning of both corium and epidermis, as a result of which 
their characteristic interdigitations largely disappear ; an increased 
pigmentation in the rete ; a shortening of the hair-follicles ; a dilata- 
tion of the sebaceous and coil-glands, the mouths of which often be- 
come blocked with epithelial detritus ; the obliteration of some vessels 
and the dilatation of others; and the disappearance of the fat-cells 
from the meshes of the connective tissue. 

In degenerative atrophy there may be fatty, amyloid, vitreous, 
and other changes of one or of several elements of the skin. Neu- 
mann described a senile atrophy with a granular degeneration and a 
vitreous swelling of the connective-tissue fibres. Schmidt, Reizen- 

1 For bibliography, see Himmel, Archiv, 1903, Ixiv., p. 47. 

519 



520 ATROPHIES. 

stein, and Tuna think these changes due to a peculiar arrangement of 
the elastic fibres and their partial degeneration into elacin, or, in com- 
bination with the collagen, into collastin and collascin (Unna). 
These changes in the elastic fibres are manifested through the peculiar 
staining qualities of the latter, and in the light of modern technique 
arc exceedingly interesting, as they occur not only in atrophy, but also 
in other cutaneous disorders. 

Treatment. — Senile atrophy cannot be remedied, but it may often 
be prevented or postponed by securing for the skin and for all the 
tissues of the body the best possible nutrition and hygiene, and by 
protecting the skin from exposure to cold and other harmful influ- 
ences. The nutrition of the skin may often be improved by the 
proper use of bran- or salt-baths, massage, electricity, or inunctions of 
oil. Cod-liver oil or other fats may usually be added to the diet 
with advantage. Care must be taken to protect all warty and other 
epithelial growths from irritation, with a view to the prevention 
of malignant changes. (See also Keratosis Senilis.) 

ATROPHIA MACULOSA ET STRIATAL 

(Atrophic Spots, Atrophoderma Striatum et Maculatum. 
Fi\, Vergetures.) 

These forms of cutaneous atrophy may conveniently be divided 
into the so-called idiopathic and the symptomatic. 

Partial Idiopathic Atrophy. — Partial idiopathic atrophy of the 
skin occurs most frequently in linear, cicatriform, often parallel striae 
or streaks (a centimetre or more in length) developed chiefly about 
the hips, buttocks, and upper portion of the thighs, in persons of both 
sexes of adult years. Less frequently these striae are observed upon 
the neck, the trunk, and the extremities. They are insidious of de- 
velopment, indelibly persistent, and appear as sensibly thinned, glis- 
tening, and often depressed lines or furrows, having a whitish hue, 
with an occasional blending of a very delicate purplish tint. They 
are usually multiple, and at times abundantly displayed, running in 
various curves, for the most part at angles with the long axis of the 
body. They occasion, as a rule, no subjective sensation. 

Much more rarely the atrophic areas occur in macular patches. 
The lesions are then fewer, more isolated, and are discovered more 
frequently upon the extremities, but also upon the trunk, varying in 
size from that of a coffee-bean to that of a chestnut. This form of 
atrophy often succeeds either an erythematous or a pigmented condi- 
tion, which very slowly changes until there is formed a dead-white, 
round or oval, often insensitive patch, more or less depressed, resem- 
bling coarsely a vaccine cicatrix. These areas usually show partial 
or complete alopecia. 

Fere and Quemonne 2 have described two singular cases of the 

1 For bibliography, see Heusa, Monatshefte, 1901, xxxii., pp. 1 and 53. 
*Le Progres med., 1881, ix., p. 837. 



ATROPHIA MACULOSA ET STRIATA. 521 

disease observed in Charcot's clinic. In one of these cases appeared 
minute, whitish, elongated cicatrices, about which there was a marked 
pigmentation of the skin. They were abundant in the lumbar region. 
In a second case brownish lines appeared over the breast of an un- 
married woman, that gradually grew paler while others appeared 
over the skin of the throat. Those lines which were recent had a 
brownish or a bluish-red color; others were of a dead-white hue; 
some appeared over the lumbar region and the upper part of the 
buttocks ; but there was none over the belly, the groins, or the thighs. 
In both cases the regions attacked were those in which there was no 
suspicion that the vergetures resulted from overdistention of the skin. 

Striae Patellares. — Bunch 1 has described and presented the litera- 
ture of this strange affection. It consists of transverse streaks of cu- 
taneous atrophy over both patellae. It usually follows typhoid fever. 

These lesions are distinguishable from sequels of scleroderma, 
syphilis, and other diseases capable of leaving atrophic areas. A 
previous history of such pathological conditions would usually be 
obtainable. In the cases in which there is precedent telangiectasis, 
hyperemia, or marked pigmentation of the spot, the diagnosis, as sev- 
eral authors suggest, is attended with some difficulty. 

Partial Symptomatic Atrophy. — Partial symptomatic atrophy of 
the skin in its simplest form may result from traumatism (the per- 
sistent marks sometimes left on the skin, for example, by a lash with 
a whip, insufficient to wound the epidermis but capable of injuring the 
deeper elastic tissue) ; or from the slow pressure of tumors (ovarian, 
uterine, mesenteric, etc.), by which the skin is distended. The well- 
known results of the stretching of the skin in a first pregnancy con- 
ducted to term are linear atrophies, at first of a violet tint, and later 
of a dead-whitish hue, that are indistinguishable, both clinically and 
pathologically, from idiopathic lesions of similar aspect. These 
atrophies are occasionally seen over the belly and thighs of male sub- 
jects with a protuberant abdomen; more rarely in persons of extreme 
thinness. Small atrophic scars result frequently from the mechanical 
pressure of inflammatory and other infiltrations in lupus, syphilis, 
leprosy, and other diseases. Partial symptomatic atrophy, with de- 
generation of the cutaneous elements (fatty, lardaceous, waxy, etc.), 
is a sequel common to a long list of cutaneous affections. 

Congenital Atrophy. 2 — This term is used to designate cases in 
which there is a congenital defect rather than an atrophy. The 
aplasia affects the scalp and consists of slightly depressed, smooth 
bald areas, coin-sized and larger, having defined borders and present 
at birth. Microscopically the epidermis and derma are thinner than 
normal and the subcutaneous fat is not present, the papillary layer 
and the muscles are poorly developed and the hair and glandular 
organs are absent. 

1 B. J. D., 1905, p. 1. 
2 Archiv, 1903, Ixvi., p. 407. 



522 ATROPHIES. 

DIFFUSE IDIOPATHIC ATROPHY. 

(aobodermatitis chronica atrophicans, atrophia maculosa 
Cutis, Axetodermia Erythematodes, Erythromelia.) 

This malady was first described by Buchwald in 1883, since which 
time a number of contributions have been made to the literature with- 
out materially adding to our knowledge of the subject beyond estab- 
lishing the clinical description of the disease. Herxheimer has pres- 
ented the most important paper on the subject in recent times. 

Symptoms. — The atrophy is apparently primary. Without preced- 
ing inflammation or other visible tissue change an atrophy of the skin 
develops in patches or in streaks. They slowly but steadily multiply, 
coalesce, and extend, until the disease affects an entire limb or an 
extensive area of cutaneous surface. The distribution is apt to be 
symmetrical. The affected skin is slightly depressed, of a bluish- 
red color, thin and wrinkled. In fully developed cases the skin pre- 
sents a crumpled cigarette-paper appearance which is highly indicative 
of the affection, or in some cases (Bronson's case) it presents a " baked- 
apple " appearance. The subcutaneous tissue is reduced ; and in some 
cases normal and also enlarged veins shine through the thin skin. 
The tendons also show more plainly than normal. The lanugo hairs 
are few in number and the glandular organs disappear. The sensa- 
tion is normal but a sense of coldness may be experienced. Herx- 
heimer (1902) showed that it could be demonstrated microscopically 
and sometimes clinically that an inflammation terminating in atrophy 
was always present on the peripheral border of the affected area. 

Erythromelia (Pick) is a special form of the disease in which 
the skin atrophy, presenting a bluish-red color, starting from the 
ankle, gradually extends up the limb, and the normal fine plexus 
of veins shines through the thin skin. 

Etiology . — The cause of the disease is unknown. In some cases 
it has followed colds. Crocker states that it may be congenital. As 
a rule it affects people in middle life, and the general health is not 
impaired. 

Histology. — There is an infiltration around the blood vessels of the 
derma in the inflammatory area, and disappearance of the elastic 
fibres as the most important finding in the atrophic area. 

Diagnosis. — It can scarcely be doubted that cases of scleroderma 
and syringomyelia have at times been included in the list of disorders 
described in this connection. 

Treatment. — Treatment is prophylactic as in senile atrophy. 

GLOSSY SKIN. 

(Atrophoderma Neuritica.) 

The " glossy fingers " described by Sir James Paget, 1 Gull, 
Mitchell, and others, are tapering, smooth, hairless, unwrinkled, 
1 Med. Times and Gaz., 1864, i., p. 58. 



GLOSSY SKIN 523 

glossy, pink, and ruddy or blotched, as if with permanent chilblains. 
One or several fingers are affected. The condition is associated with 
neuralgia or nervous impairment indicated by abnormal sensations, 
as of heat or intense burning. There is usually, however a precedent, 
or subsequent neuralgic pain, with incurvation of the nails and at 
times a heaping up of epidermal masses beneath the free border of 
the nail. In consequence of retraction of the skin over the distal 
phalanges the terminal extremity of the digit appears thin and drawn 
away from the nail-bed. 

The complications of this condition are changes in the sebaceous 
glands and the coil-glands, loss of hair over the phalanges, excoria- 
tions, and in severe cases ulceration. 

This disorder may be associated with grave systemic states, such 
as lepra, or with gout and rheumatism. It is marked clearly in some 
classical instances of severe palmar and plantar keratosis. It is 
found also in those in whom for any reason the circulation is feeble 
and there has been exposure of the extremities to severe cold. It has 
likewise been noted as the result of centric and peripheral changes 
in the nervous system. In some cases the cause is recognized as a 
neuritis ; in other cases it may more properly be classed with the 
trophoneuroses of the skin. The relations of this and several sym- 
metrical disorders of the hands and feet to the so-called " perforating 
ulcer of the foot," " asphyxia " of the extremities, " symmetrical gan- 
grene " of the extremities, and so-called " dying of the fingers," all 
manifestly trophoneurotic affections (see the chapter on this subject), 
have not yet satisfactorily been established. 

Blanching Atrophy of the Skin. — This peculiar degeneration of the 
integument is characterized by an unnatural whiteness or pallor of 
the skin-surface, with considerable tension and tenuity of the epider- 
mis, usually limited to the extremities (the arms and palmar and 
plantar faces of the hands and feet, and the thighs and legs). Moder- 
ate exfoliation occurs, and, in connection with the tension to which 
the skin is subjected, is responsible for more or less painful subjective 
sensations. The disorder is chronic in its course and it may originate 
in infancy. 

This condition is occasionally illustrated by persons affected with 
a sensori-motor paralysis of one limb, when the muscles waste and 
the fat-cells persist, multiply, or wholly disappear. The skin of such 
limbs, wholly or in patches, becomes unnaturally soft and delicate, and 
undergoes a loss of pigment and hairs, at the same time that its bulk 
actually diminishes. The nails may participate in the process. In 
other cases of trophic disturbance the skin shrivels and assumes, in- 
stead of a whitish, a yellowish or yellowish-gray tinge. 



524 ATBOPEIES. 

MULTIPLE BENIGN TUMOR-LIKE NEW-GROWTHS 
OF THE SKIN. 

rmlcr this title Schweninger and Buzzi 1 describe and figure le- 
sions occurring chiefly on the back, but also on the arms and the chin 
of a married woman twenty-nine years of age. These lesions were 
bean- to coin-sized, bluish-white and slate-tinted formations, with deli- 
cate telangiectases over the surface of some. By pressure most of 
them could be forced into a shallow pit in the underlying tissue, the 
tumor returning like a ventral hernia after removal of the pressure. 
The Larger seemed to spring from the smaller lesions, and as they 
increased in age became flatter, less white, harder, and less compres- 
sible. They produced no subjective sensations and in no way inter- 
fered with the general health of the patient. The vigorous treatment 
adopted seemed to have but little effect on the growths. 

Under the microscope sections of the excised skin showed that 
elastic fibres were in every instance wholly wanting in the affected 
portions, nor were there signs of remnants or of degeneration-products 
of these elements. It was assumed that there had been in each 
locality a retraction of the elastic tissue, and that the resulting dis- 
ease was due to a disturbance of the static balance, the overgrowth 
developing until the equilibrium was established. A growth of new 
and young cells was visible about the adventitia of the vessels and most 
of the accessory organs of the skin. 

KRAUROSIS VULV^ 

(Gr., Kpavpog, hard.) 

The rare and curious condition to which this name was first 
given by Breisky in 1885, is now generally recognized under the 
title given by him, though Weir of Xew York first described the dis- 
order as an ichthyosis, and was followed by Tait, describing a similar 
condition. Recently George Thibierge, of the St. Louis Hospital in 
Paris has, after a large experience, described the disease in its several 

1 Internat. Atlas, 1890-1891, v. 

2 Bibliography : Baldy and Williams, Amer. Jour. Med. Sci., cxxviii., 528. 
Jayle, Rev. de gyn. et de chir. abdom., July-Aug., 1906, 633. Thibierge, An- 
nates, 1908, s. iv., ix., p. 1. Weir, X. Y. Med. Jour., March, 1875. Tait, Ser- 
piginous Vascular Degeneration of the Nymphs, 1877. Fleischmann, Prager. 
innl. Wochenschr., 1886, Xo. 36. Heitzman, Breisky, Trans. Amer. Derm. Assoc, 
Berlin, 1888. p. 60. Smith, Buffalo Med. and Surg. Journ., 1890-91, xxx., 
p. 283. Hallowell, Xorthwestern Lancet, xi., 1891. Frederick, The Times and 
Reg., 1891, xxii., Xo. 8. Orthmann, Zeitsch. f. Geb. und Gyn., Bd. xix., p. 
283. Adam, Australian Med. Journ., Melbourne, 1892, p. 407. Bartels, S., 
Inaug. Diss., Bonn, 1892. Reed, Amer. Gyn. and Obstet. Journ., X. Y., 1894, 
v., p, 556. Martin, A.. Centralb. fiir Gyn", 1894, Xo. 13, pp. 310, 323 u. 394; 
Volkmann klin. Vortr., X.F.. Xo. 102. Marocco, Rif. med. Xapoli, x., 1894. 
Blisha, Zeitschr. f. Geb., Bd. xxiv., p. 1460. Rona, Orvosi hetilap, 1894, No. 
13. Gordes, M. Monats. f. Geb. u. Gyn., Bd. lii., p. 305. Longyear, Amer. 
Journ. of Obstet., Dec, 1895, p. 823. Neumann, Wien. klin. Wochenschr., 1896, 
p. 211. Pichevin et Pettit, Semain. Gyn., Paris, 1897, pp. 49-51. Pfannesteil, 
Gesellsch. fiir Vated Cult., Bresl., 1896. Le Rov Du Barres, Semain. Gyn., Paris, 
1897, ii., p. 114. Veit, J., Handbuch der Gyniikologie, 1898, Bd. iii., pp. 145-154. 



KRAUROSIS VVLVM. 525 

types. He calls attention to the fact that Breisky's original descrip- 
tion covered one only of the clinical varieties of the disease. 

The forms recognized to-day by both gynecologists and dermatolo- 
gists are : 

1. The white form — leucoplasic — which may be either simple or 
syphilitic in character. 

2. The red — or inflammatory form — which may be betrayed with 
either follicular or vascular predominance of lesions. 

3. The senile form. 

4. The post-operative. 

In each of these the picture presented is somewhat different. 

The clinical features of the disease, whether in one form or an- 
other, and whether or not commingled, are commonly striking. 

Symptoms. — The most of the patients are women either of ad- 
vanced years, at or near the menopause, or younger women who have 
suffered ablation of the uterus or ovaries. The vulva is commonly 
shrunken, atrophic, dry, or oddly furrowed. The parts may be sym- 
metrically or irregularly involved, the labia majora appearing to have 
been obliterated when the disease is at its height, the labia minora ab- 
sent or fused in an indistinguishable tissue. The shrunken genitalia, 
the nymphs, the clitoris and its hood, the vestibulum, and the entire 
vulvar ring are eventually involved and produce a characteristic 
atrophy of the entire organ. The pubic hairs whiten or fall and the 
mons flattens. 

According as one or another type of the disease develops, the pic- 
ture changes : In some cases the parts are whitish and dry ; in other 
cases they are smeared with a thin mucus; in others the skin is 
furrowed, wrinkled, pitted, spotted, or scaling ; in yet others the sub- 
cutaneous vessels become visible beneath the thinned and glazed epi- 
dermis. The clitoris may disappear beneath its hood and be repre- 
sented by a mere depression. The orificium vaginae may be so re- 
duced as to scarcely permit the introduction of the little finger. In 
some cases, the disease involves also the anal and peri-anal region. 
The color of the retracted tissues may be whitish, reddish, pinkish, 
yellowish, or even bluish. In almost all types of the disease the re- 
tracted tissues have a thoroughly characteristic glistening aspect, 
shining as if varnished. 

Several cases have come under my observation, two ultimately de- 
veloping as a carcinoma, the others strikingly suggestive of leuco- 
plakia. Jayle, discussing the relation of the last named disorder to 
kraurosis, calls attention to the absence of any tendency to retraction 
in the pure types of leucoplasia; and yet believes that the two af- 
fections may coexist ("Leucoplasic Kraurosis"). 

Etiology. — The cause of kraurosis vulvae is obscure. In ten per 
cent, of cases the disease is complicated with carcinoma, though 
whether originating or following in the course of the last named dis- 
order, is not determined. Many believe that an inflammatory stage 
precedes the atrophic contraction. A number of cases have been 



526 atrophies. 

shown to be strictly post-operative, following ablation of the uterus or 
ovaries or both. Syphilis, blennorrhagia, neurotic influences, catar- 
rhal discharges from the neighboring mucous tracts, scratching, and 
traumatism have all been cited as effective in its production; but 
most of these causes, and in particular venereal diseases, have been 
discredited as effective agents. 

Pathology. — Yeit, Martin, Baldy and Williams agree in believ- 
ing that kraurosis of the vulva is a purely inflammatory disease pro- 
duced by local causes. Jayle recognizing in many cases the atrophic 
nature of the process, finds nothing either in the epiderm or derma 
sufficient to explain the special phenomena exhibited. Thibierge, 
finding in some of his patients lesions of the mucous membranes of 
the mouth, corresponding with those recognized in the vulva, be- 
lieves that the entire process is under the impulse of one general 
cause, viz., a senile atrophic involution of the integumentary system. 
The striking localization in the genitalia of so many cases is due to 
the influence of the ovaries and uterus. 

Treatment. — The treatment is largely surgical, though radiother- 
apy has furnished good results. Medicinal treatment is indicated in 
the leucoplasic cases, in which cauterization had been practiced with 
good results. After surgical ablation, wholly or in part, of the scle- 
rosed mass, plastic operations have been successfully practiced. 

Prognosis. — The prognosis is unfavorable for the most of cases. 
The course of the disease is toward persistency and slow extension of 
symptoms. 

PERFORATING ULCER OF THE FOOT. 

(Malum Perforans Pedis. Ft., Mat, Peeforant du Pied.) 
This disorder, first named by Vesigne, has been studied by Savory 
and Butlin, 1 Gasquel, 2 and others. The name is an unfortunate one, 
since many cases to be classed only in this category have neither ul- 
cerative nor perforating symptoms. 

Symptoms. — The patient frequently complains of neuralgic and 
rheumatic pains and anaesthesia is usually present. The first objec- 
tive symptom is a proliferating thickening of the epidermis like a 
corn usually single, occasionally multiple, appearing over a point of 
pressure (first or fifth metatarsophalangeal or metacarpophalangeal 
joint, etc.). Inflammation and suppuration proceed beneath this 
thickening, spreading first to the soft parts of -the sole and perhaps 
to the bone itself. Gradually a sinus forms, reaching from the side 
of the corn to the deeper parts involved. When fully developed the 
lesion consists of an ulcer the surface of which is covered with a 
luxuriant growth of granulations and surrounded by an extensive 
collar of callous tissue. A probe introduced into the granulation 
tissue passes into a sinus and may lead to dead bone. 

Tn some cases the nails are altered ; superfluous hair grows on the 

1 Mcd.-Ohir. Trans., 1879, lx., p. 46. 

2 These de Paris, July, 1890 ; a resume of ninety-one collected cases. 



PLATE XXIII 




\ 




Malum Perforans Pedis, with Symmetrical Keratoma 
of the Palms and Soles. 

(From a water-color sketch.) 



PERFORATING ULCER OF FOOT. 527 

dorsal surface of the foot and the skin of the involved extremity; 
pigmentation, erythema, or eczema may occur; and the parts may 
become affected with either anidrosis or hyperidrosis. 

The patients are often young adults. The palms when involved 
never exhibit the translucent, yellowish, wash-leather-like appear- 
ance of the same condition of the soles, but rather suggest the dry, 
scaly features of the palms in certain forms of erythematous eczema 
of these parts, but always without itching, and with coincident 
plantar tylosis. The soles, however, present the typical appearance 
of callositas throughout the entire region, the callosity reaching some- 
what upward over the heel, and in certain patients relatively spar- 
ing the instep. In some cases the nails are not involved. The feet 
are always as cold to the touch as in pernio. 

Etiology". — The disease is caused by pressure or injury to a foot 
which presents a lessened innervation either from disease of the spinal 
cord or peripheral neuritis. It is more common in locomotor ataxia 
than in any other disease, but it may be observed in prolonged sciat- 
ica, or in neuritis of alcoholism, syphilis, leprosy, or diabetes. 

Pathology. — Histological examination has shown destruction of 
the myelin and axis-cylinder of twigs of nerves supplying the affected 
parts. According to Savory and Butlin, the sensory and nutrient 
fibrils of the involved nerves degenerate in consequence of pressure 
exercised upon them, by increase of the endoneurium, the motor 
fibrils escaping owing to their large size and thicker medullary sheath, 
a view untenable for all cases. Thomasczewski 1 reports ten cases as- 
sociated with tabes, leprosy, diabetes, or cerebral or spinal disease, 
the location, characters, and course of the ulcers being practically 
the same in all the cases. He believes the ulcers are due to trophic 
changes in the tissues resulting from systemic disease, usually that of 
the central nervous system, though the local ana3sthesia and pressure 
are undoubtedly etiological factors in some instances. 

Diagnosis. — The diagnosis is between Madura foot, tuberculosis, 
and simple callositas, a distinction readily established by the evident 
neurotic phenomena seen in perforating disease of the foot. 

Treatment. — By curetting away all diseased tissue and putting the 
foot completely at rest the ulcer may be made to heal, but it usually 
reappears when the patient again tries to walk. Amputation of the 
toe and joint affected avails little. It is not unusual even after ampu- 
tation of the foot for the disease to appear in the stump. A roborant 
treatment and mechanical devices to prevent the use of the foot are to 
be advised in most cases. 

Prognosis. — The prognosis is doubtful. 

1 Munch, med. Wchnschrift., 1902, xlix., pp. 779 and 840. 



528 ATROPHIES. 

MORVAN'S DISEASE. 
(Syringomyelia, Analgesic Paralysis with Whitlow. 

Fr., I 'AX A IMS AxALGESIQUE.) 

Morvan's disease is a paretic affection of the spinal cord, chiefly 
involving the upper extremities, accompanied by pain and producing 
a series of whitlows, affecting first one side of the body and then 
the other. 

Symptoms. — In this disorder the arm is commonly first involved, 
the approach of the disease being insidious and usually first noticed 
on account of the production of pain and some loss of nervous and 
muscular power. At times the first sign of involvement is the produc- 
tion of whitlows, which either early or late in every case are tolerably 
sure to appear. In other instances the disease first displays an anal- 
gesia similar to that occurring in some subjects of lepra, the attempt 
having been made to establish a relation between the two diseases. 1 
In time atrophy of the interosseous muscles, of the flexors of the 
wrist, and of the tissues forming the thenar and hypothenar eminences 
may result. The integument of the affected limb has a bluish or em- 
purpled look ; it may be thinned or thickened, and the seat of fissures, 
vesicles, and bulla?, as well as of the characteristic whitlows, which 
vary in number from two to four or six. Ulceration, extending as 
deeply as to the tendinous sheaths, may result, and, as a consequence 
of one or more of the changes described above, the phalanges may 
necrose and be separated from the hand. 

Trophic changes arise in connection with the disease, pointing 
for the most part to an origin in disturbances of the centric nervous 
system. Among these disturbances may be named: hyperidrosis ; 
diminution of, variability in, or complete absence of the reflexes; 
visual changes; contracture of the fingers; and a general distortion 
of the hand. Scoliosis and arthritic complications have been recorded 
in a number of cases. 

The disease is usually protracted in its course, lasting in some 
cases for a quarter of a century. 

Etiology. — The affection may develop first in childhood and last 
until middle life and longer, though more often it is first noticed 
after the occurrence of puberty. Women are much less often affected 
than men. Traumatism, malaria, and rheumatism have all been cited 
as possible causes of the disease. Its exact etiology is obscure. 

Pathology. — Neuritis and thickening of the neurilemma have been 
discovered in the nerves distributed to the affected parts; as also 
sclerosis of the posterior cornua and columns of the cord. The cavi- 
ties recognized in the central canal, distended with fluid, are supposed 
to be due to absorption of gliomata. 

Diagnosis. — The recognition of a fully developed case of Morvan's 

1 Cf. Zambaco, Trans. First Internat. Leprosy Congress, Berlin, 1889; Dyer, 
New Orleans Med. and Surg. Jour., 1893, xxi., p. 81; and Calderone, Giorn. ital., 
L901, vi., p. 756 (includes survey of the subject and bibliography). 



MOBVAN'S DISEASE. 529 

disease is readily established by taking into consideration the paretic 
symptoms present, the whitlows, and the perversions of sensation, 
more particularly in appreciation of temperature-changes, pain, and 
contact with foreign bodies. Attention has already been directed 
to the striking resemblance between certain phenomena of anaesthetic 
lepra and those of syringomyelia. Scleroderma and glossy fingers are 
to be differentiated by the special peculiarities of each. 

Treatment. — Treatment is to be conducted on the general princi- 
ples, surgical and medical, relied upon for meeting the indications of 
each case. In general the hygienic and dietetic management of the 
patient with a highly roborant regimen is conducive to recovery. 
Many of the subjects of the disease have been reported as relieved or 
even wholly cured. 



34 



CLASS V. 
PIGMENT ANOMALIES. 



LENTIGO. 

(Lat., lens, a freckle.) 

(Freckle, Epheeis. Ft., Epheeide, Lektiele; Ger., Sommee- 
sprosse.) 

Symptoms. — This condition is due to excessive and irregular de- 
posit of pigment in the skin, producing the pinhead- to bean-sized 
spots of circinate or of irregular outline, frequently grouped and even 
confluent, which spots are commonly designated as " freckles." They 
are most frequently seen symmetrically distributed on those parts of 
the body ordinarily exposed to the light and heat of the sun and to. at- 
mospheric influences, such as the face, the neck, and the backs of the 
hands in persons of both sexes. In those individuals whose bodies 
are to a greater extent similarly exposed they occur upon the chest, the 
back, and over the extremities. In other persons they may be seen 
upon parts not thus exposed, such as the penis, the scrotum, and the 
inner surfaces of the thighs, a fact which indicates that freckles are 
not always the result of the operation of the agencies noted above. 
They vary in color from light yellow, salmon, or red to the deepest 
brown ; and are most noticeable in those having red hair and a delicate 
skin. Freckles occur rarely in infancy, partly, perhaps, on account of 
the infrequency of outdoor exposure in tender years. They are usu- 
ally seen first about the age of the sixth to the eighth year. They are 
commonly observed in mulattoes, individuals of a race particularly 
disposed to anomalies of pigment-distribution. Once developed, the 
lesions may persist through life without marked alteration; or may 
fade with each recurrence of the season of winter ; or in milder cases 
may disappear. They usually share in the atrophic changes of old 
age, and, when persisting to that period, may then spontaneously dis- 
appear. They are not the source of subjective sensation. 

A special form of lentigo frequently affects the covered parts of 
the body in fibroma molluscum, in xeroderma pigmentosum, and 
where the freckles are unilateral or arranged in streaks like a linear 
nsevus. This variety is a manifestation of defect in development. 
In doubtful cases it could be distinguished from the ordinary form by 
microscopical examination of the tissue as Unna has shown that the 
rete-pegs are not properly developed in this variety. They present a 
dumb-bell shape or they form grotesque figures. 

531 



532 PIGMENT ANOMALIES. 

Etiology. — Freckles arc unquestionably produced and aggravated 
at times by tbe action of the light and heat of the sun, as common 
experience suggests ; but it is evident that these forces must act upon a 
susceptible skin. Of a hundred sailors exposed in precisely similar 
situations on a long cruise, some of the number will uniformly be 
" tanned " and others deeply " freckled." Attention has been called 
to the occasional occurrence of lentigo in the protected parts of the 
skin. Exposure to sea-air and fog, with obscuration of the sun, is suf- 
ficient to produce the result. 

Pathology. — Freckles are due to an increased deposit of pigment 
in definite areas of the rete mncosum of the epidermis, never in the 
corium. The pigment accumulates densely in and about the prickle- 
cells, which become apparently softer and lose their spines at a later 
stage. Unna divides pigmentations of the skin into two classes: 
hemosiderosis (due to granules containing iron) and melanosis (due 
to pigments in which the presence of iron has not been determined). 
In lentigo no iron-reaction has been recognized. Lassar urges, with 
strong probability, that there is always a congenital predisposition to 
these pigment-formations that requires certain external conditions for 
development. 

Treatment. — The treatment of lentigines is that of chloasma and 
other pigmentations of the surface. Wertheim, of Vienna, advises: 

]J Hydrarg. amnion, niuriat., 

Bismuth, magister., 

Ungt. glycerini, 
Sig. To be applied every other night. 

Bulkley employs: 

]£ Hydrarg. chlor. corros., gr. vj 

Acid, acetic, dilut., f 3ij ; 

Boracis, 3 i j ; 2 

Aq. ros., f^iv; 120 M. 

Sig. To be applied night and morning, at first with gentle brushing; 

afterward by rubbing. 

Hardaway touches each freckle with a rather stiff needle con- 
nected with the negative pole of a galvanic battery, and he finds the 
results satisfactory. 

Most of the methods employed by charlatans for the removal 
of freckles depend for their success upon thorough blistering of the 
surface. Inasmuch as by this process the epidermis is removed, the 
pigment of its cells is also measurably removed with it, and the 
new epidermis is for a time free from blemish. But in all such cases 
the ultimate result is a deeper and more persistent pigmentation than 
that which was previously visible. 

ANOMALIES OF PIGMENTATION. 

Symptoms. — In melanodermia the skin is either diffusely dis- 
colored in various shades, or the maculations occur in patches larger 



g r - Ivj; 


3 


75 


g r - ] ij; 


3 


50 


Sj; 


30 


M 



ANOMALIES OF PIGMENTATION. 533 

than those of lentigo, fairly well denned, and irregular in contour, 
the so-called "liver-spots." In color they vary from a scarcely per- 
ceptible staining of the skin that requires a strong light for its de- 
tection, to a deep-yellow, a yellowish-green, a chocolate-brown, or a 
blackish shade (Melanoderma). They may be idiopathic or symp- 
tomatic in character. The idiopathic varieties of pigmentation are 
produced by all externally operating agencies, in consequence of which 
an undue afflux of blood is persistently determined to any portion of 
the skin. It is largely from the blood that the pigment is derived, 
hence the stains produced by the pigment are, to a certain extent at 
least, proportioned to the hyperemia, stasis, or extravasation of the 
vascular fluid. Among these externally operating agencies may be 
named pressure and friction (as over the part covered by the pad of 
a truss) ; traumatism (as after the severe scratching of the skin af- 
fected with lice, eczema, or scabies) ; heat (as in diffuse "tanning" 
of the face, or "sunburn" following exposure to the solar rays); 
and the toxic or irritating effect of externally applied substances, such 
as mustard, capsicum, cantharides, and other articles capable of pro- 
ducing either vesication or pustulation of the skin-surface. Per- 
sistent or even permanent pigmentation of the skin upon, the face, 
shoulders, and bosom, especially of young women, may be produced 
by the repeated application of such topical medicaments. 

The symptomatic varieties of pigmentation are the result of dis- 
orders either systemic or those involving the internal organs. They 
occur as either circumscribed or diffused, localized or generalized, 
spots, mottlings, stainings, or " masks " of the skin, and they vary in 
color from the lightest to the darkest shades. One of the most com- 
mon, and at the same time the most marked of these varieties, is 

Chloasma Uterinum. — Chloasma uterinum is so called because of its 
frequent association with certain physiological or pathological con- 
ditions of the uterus, both among married and single women. Thus 
in pregnancy, sterility, hysteria, chlorosis, ovarian disorders and tu- 
mors, and functional derangements of the uterus there can be observed 
at times a facial discoloration extending equably over the forehead 
and reaching nearly to the line of the hairs at the scalp, in the form 
of a faint or a decidedly reddish-yellow or deep-brownish tinge. At 
other times the discoloration is macular and asymmetrical, involving 
the eyelids, the cheeks, the lips, or the chin. When the chloasma 
assumes the mask-like form it is usually most pronounced over the 
forehead, but it may involve the whole facial region, being less dis- 
tinctly defined below than above. Similarly, the well-known changes 
occur in the areola of the nipple, along the linea alba, and about the 
external genitalia. Pigmentations of this variety are caused by the 
absorption of uterine toxines. 

Chloasma (or Melanoderma) Cachecticorum. — This is another of the 
symptomatic pigment-disorders, characterized by changes in the color 
of the integument of the subjects of tuberculosis, syphilis, cancer, 
chronic alcoholism, malaria, and other disorders. Its hue varies be- 
tween a faintly defined yellow to a deep chocolate. 



534 PIGMENT ANOMALIES. 

Hemochromatosis. — This is a pigmentation of the skin and viscera 
associated with hypertrophic cirrhosis of the liver and extensive scle- 
rotic changes in the pancreas ; it may terminate in glycosuria and in 
the terminal stage it is called Bronze diabetes. 

Addison's Disease. — Addison's disease, formerly thought to be due 
exclusively to lesions of the suprarenal capsules, is of the same nature, 
and is characterized by a peculiar bronzing of the skin. Overbeck 
and Greenhow have shown that the capsules may be destroyed wholly 
without changes in the skin-color resulting. The pigmentation may 
be general or be partial, and in the latter case is without definite lines 
of demarcation. It is commonly most pronounced over the face and 
neck, the scrotum, the groins, the axilla, and the nipple and areola. 
The hairs become coarse and dark ; and dark or grayish-brown patches 
are at times visible over the mucous surface of the lips, the gums, and 
other parts of the mouth. The bronze or mulatto-like color of the 
skin is intensified by stimulation or erosion of the cutaneous surface, 
and by exposure to light. In these cases there are generally marked 
asthenia and a feeble pulse, with anorexia and other signs of gastro- 
intestinal disorder. When the result is fatal there may or may 
not be recognized pathological alterations of the suprarenal capsules. 
The pigment when examined furnishes no iron-reaction. 

Hadra, of Berlin, reports a case of Addison's disease cured by 
extirpation of a small apple-sized tubercular neoplasm of the retro- 
peritoneal glands. A suprarenal capsule was contained in the 
growth. 1 

In Graves' disease 2 there may be cutaneous telangiectases, or 
freckle-like, patchy or diffuse pigmentation of the skin, usually most 
marked in regions which have normally more pigment than the gen- 
eral surface of the body. 

Among the cutaneous disorders capable of producing skin-pig- 
mentation may be named scleroderma, lepra, angioma pigmentosum 
et atrophicum, eczema (especially e venis varicosis), and general ex- 
foliative dermatitis. 

From all the above-named discolorations, which are due solely to 
deposition in excess of coloring-matters normally existing in the 
skin, it is necessary to distinguish the various dyschromia? which are 
owing to the introduction into the integument of coloring substances, 
either supplied by other portions of the body or foreign to it. Thus, 
in Icterus the bile may color the skin from a light-yellow to a dark- 
chrome shade, the duration and severity of the cutaneous symptoms 
depending upon the nature and gravity of the hepatic disease. This 
condition is frequently accompanied by pruritus in various grades 
of severity, the exact causes of which are obscure. 

Pigmentation from Ingestion of Arsenic. — The administration of 
arsenic in full doses for relief of nervous disorders in adults and chil- 
led. Week, 1896. 

2 For a review of the cutaneous changes seen in Graves ' disease with bibli- 
ography, see Dore, B. J. D., 1900, xii., p. 353; Hyde and McEwen, Amer. Jour. 
Med. Sci., 1903, cxxv., p. 1000; Hyde, B. J. D., Feb., 1908, p. 33. 



ANOMALIES OF PIGMENTATION. 535 

dren is frequently followed by a characteristic dull-brownish or dirty- 
colored discoloration of the skin of the neck and chest. In connec- 
tion with these arsenical pigmentations, which are in some instances 
obstinate and generalized, may occur palmar or plantar keratoses 
and hyperhidrosis as well as keratoses appearing elsewhere, which 
may be the starting-point of an epithelioma. (0/. Chapter on Derm- 
atitis medicamentosa.) 

Argyria. — A bluish, bluish-gray, slate-colored, or bronzed colora- 
tion of the skin may result from ingestion of silver nitrate. Argyria 
is most commonly the result of the administration of the drug in the 
treatment of epilepsy, but it is said to have also resulted from the 
topical application of silver-crayons to the throat, to the conjunctivae, 
and even to the skin. Under what form the silver produces this 
effect, whether as an albuminate or other salt, is not known. The 
deposition, however, occurs in the form of minute particles of the 
metal in the connective tissue of the derma. The discolorations are 
most evident upon the parts of the skin exposed to the light, as the 
face and hands; but the chest and the lower extremities may be 
stained similarly. The connective tissue of the viscera is at times 
also involved, showing thus that the action of light is not essential 
to the production of the dyschromia. Two cases are reported as re- 
lieved by the administration of potassium iodide. 

Tattooing^ — By the process of tattooing mineral and vegetable sub- 
stances are directly introduced into the corium by means of needles, 
for the production in the skin of various devices in colors. Individ- 
uals whose entire integument has been thus artificially covered with 
figures of different patterns by tattooing with indigo, vermilion, and 
cinnabar, are from time to time publicly exhibited. The results are 
indelible. Post mortem these pigments have been discovered not only 
in the derma, but also in the lymphatic ganglia nearest the site of 
their introduction. 

Mongolian 1 Pigment Spots. — Infants of the darker races occasionally 
present bluish areas of pigmentation over the sacrum and buttocks 
which contrast strongly with the color of the general integument. 
These spots have been variously interpretated. They are not char- 
acteristic of the Mongolian race as was formerly supposed. 2 

Pigmentation of the Skin following Nervous Shock. — Bark 3 has re- 
ported the case of a woman 70 years of age, whose entire cutaneous 
surface turned black the day after the suicide of her daughter. The 
pigmentation persisted and she died two years later of pneumonia. 
Post mortem acute lobar pneumonia was recognized. 

Pathology. — The lentigines, ephelides, and chloasmata are all due 
to excessive deposit of the natural pigment of the body in the rete 
mucosum of the epidermis. Restoration of the normal color of the 

1 American Anthropologist, March, 1907. 

2 Ashmead, A. S., The mulberry-colored spots on the skin of the lower spine of 
Japanese and other dark races; a sign of negro descent. J. C. D., 1905; xxiii.; 
pp. 203-^214. 

3 Archiv, 1898, adv., p. 283. 



536 PIGMENT ANOMALIES. 

skin is usually proportioned to the extent and depth of the deposit, 
but the process is always very gradual. It can well be studied in the 
slow bleaching of the pigmentation of syphilitic cicatrices upon the 
lower extremities. In the dyschromias due to the introduction of 
coloring matters foreign to the body or foreign to the skin, the corium 
and the subcutaneous connective tissue are commonly stained. 

The origin of the pigment in the skin being still undetermined, 
pathologists are unsettled as to the question whether migratory pig- 
ment-conveying cells are responsible for the change of color in the 
skin or whether the pigment-granules themselves migrate. Kaposi, 
J arisen, and a few others believe that pigment is formed in the rete. 
Unna believes there are two distinct kinds of pigment, not however 
fully differentiated, formed in the corium and carried through the 
lymphatic spaces to the rete. Ehrmann, 1 after much careful inves- 
tigation, states that there are special pigment-cells, or " melanoblasts," 
which are formed in the embryo from the mesoderm. These cells 
perpetuate themselves, being thus independent of all other bodies, 
and are connected by long processes or threads of protoplasm, along 
which the pigment flows in a viscous state. The cells obtain their 
pigment from the ha?moglobin of the blood. All pigment outside of 
these cells he considers hsematin-detritus. In some of these cases 
there is no change in the walls of the blood-vessels and there are no 
signs of blood-extravasation. 

Diagnosis. — The diagnosis of cutaneous pigment-hypertrophies is 
readily effected by observing: the persistence of the discoloration 
under pressure ; the absence of all symptoms of hyperemia, inflam- 
mation, and secondary changes in the skin ; and the characteristic 
shades of color presented to the eye. In tinea versicolor there is 
usually slight furfuraceous desquamation, and the existence of a 
vegetable parasite is readily demonstrated by the microscope. The 
rare pigmentary syphilide is usually seen upon the neck and shoul- 
ders of infected women in the form of yellowish to brownish macula- 
tions, often arranged in an irregular network. The lesion is, indeed, 
one of the symptomatic chloasmata. 

Treatment. — In all the symptomatic pigment-anomalies the indi- 
cations for treatment are presented by the disease which begets the 
cutaneous disorder. 

The local treatment of both the idiopathic and symptomatic varie- 
ties of the affection demands the use of external applications which 
will hasten the physiological reproduction of the epidermis, substi- 
tuting thus new and unpigmented for old and pigmented epithelia. 
This process must also be accomplished without the artificial pro- 
duction of such an hyperemia as will tend to add to the very color- 
ation which it is attempted to relieve. The substances used for the 
slow accomplishment of this end are borax, sulphur, tincture of iodine, 

^ibliotheca Medica D. IT., Part VI., 1896, W. C. Fisher & Co. (an illustrated 
monograph, giving results of his researches, and full bibliography) ; see also 
Ehrmann and Oppenheim, Archiv, 1903, lxv., p. 323 (report of further research, 
and complete bibliography). 



ANOMALIES OF PIGMENTATION. 



537 



potassium and sodium hydroxides (including the soaps of these alka- 
lies), and the mercurials. None of these substances is more generally 
employed than corrosive sublimate, which constitutes the basis of 
most of the cosmetic lotions sold in the shops. 

The following formulas are given by White 1 for use in the evening. 
The preparation in each case should be left upon the affected surface 
during the night, and be removed by a soap-and-water washing in the 
morning. They are to be used for weeks in succession, but only 
after a cautious preliminary testing of the sensitiveness of the skin to 
their action. To avoid the possibility of error, the practitioner would 
do well to order a poison-label upon all vials containing the sublimate : 



5 Hydrarg. am. chlor. 
Bismuth, magister., 
Amyl., \ 
Glycerin., J 

]£ Ammon. muriat., 
Aq. Colognien., 
Aq. dest., 



S 



Hydrarg. bichlorid. 
Acid, mur, dil., 
Glycerin., 
Alcoholis, \ 
Aq. ros., J 
Aq. dest., 



3ij; 

Jss; 

3ss; 

fSJ; 



gr, vj: 



i 8| 
151 



30 
240 



M. 



M. 



a 60| 
120 1 M. 



The following formulas for ointments are given by Kaposi 



$ 



Hydrarg. ammon. 
Sodse biborat., 
01. rosmarin., 
Ungent. simpl., 

Acid, boric, \ 

Cer. albse, j 

Paraffin., 

01. amygd. dulc, 



aa ^ss; 
gtts. 

Si 

aa 3j; 
3ij; 

Br, 



15| 

If 
30| 

■ 41 

81 

30| 



M. 



M. 



Van Harlingen recommends : 



Hydrarg. chlor. corros., 
Zinci sulphatis, ") 
Plumbi subaeetat., j 
Aq. dest.. 



gr. vss; 
aa 3ss; 
f ^iv ; 



Sig. Lotion, for external use, morning and evening. 



U2| 

120 1 



M. 



Other applications advised are: alcohol, followed by the use for 
several hours after, of a plaster of ammoniated mercury; 2 parts 
of magnesium carbonate and zinc oxide, 4 parts of pure kaolin 
and glycerin, and 10 parts of vaselin ; chloroform 100 parts, chrysa- 
robin 15 parts (Leloir) ; hydrogen peroxide ; diluted acetic, car- 
bolic, muriatic, and nitric acids ; 1 to 2 parts of salicylic acid, in 
paste or powder, to 20 parts of base ; and solutions of mercuric chlor- 
ide in collodion, 1 part to 30, employed with great caution. 

a Loc. eit. 



538 PIGMENT AXOMALIES. 

The rapid removal of pigmented patches is accomplished, in 
Vienna, by covering the part with strips of linen dipped in an aqueous 
or an alcoholic solution of corrosive sublimate of the strength of 4 
grains (0.25) to the ounce (30.), with which solution the dressing 
is also occasionally moistened. Vesiculation is usually accomplished 
in about four hours, when the serum is evacuated by puncture, and 
the detached epidermis is covered with an inert dusting-powder. The 
resulting crusts fall in about eight days. The procedure is attended 
with danger of producing in the end the precise deformity which it 
seeks to remedy, a danger explained above. 

Another method of removing tattoo-marks and pigmented nsevi, 
successfully employed by French dermatologists, consists in tattooing 
the region, previously rendered aseptic, with a solution of 30 parts of 
zinc chloride to 40 parts of water. If properly done, the resulting in- 
flammation is slight, and after a few days there forms a superficial 
crust which remains about a week and then falls, leaving a slight scar 
which becomes almost imperceptible. This method succeeds in a 
few cases, but requires skill and care in its application in order to 
obtain good results and to avoid suppuration and deep cicatrization. 
The internal administration of potassium iodide, recommended for 
the removal of argyria, has often failed. 

Prognosis. — The prognosis is in all cases uncertain. There is 
strong reason to believe that the local treatment of these dyschromias 
is, in the long run, ineffective. Those methods which effectually 
and brilliantly accomplish the desired end are almost invariably fol- 
lowed by deeper pigmentation than that which it was attempted to re- 
move ; those operating more slowly have, probably, a less speedy, but 
scarcely more disguised sequel. It is likely that local treatment of 
these pigmented states will ere long be abandoned. The treatment 
intelligently directed to the cause of each discoloration is that which 
in the end proves most satisfactory. 

LEUCODERMA. 

(Gr., /xvkoq, white; depfia, skin.) 
(Achromia, Lettcasmus, Partial Albinism.) 

In the following pages the name leucoderma is employed to desig- 
nate the pigment-atrophy which is partial and congenital ; albinismus, 
that which is universal and congenital; vitiligo, that which is 
acquired. 

In leucoderma, the patients being most often though not exclu- 
sively of the colored races, one or several whitish or rosy-whitish 
patches or bands, varying in size, outline, or situation, and unpro- 
vided with pigment, may be seen at birth. These patches may have a 
symmetrical arrangement, in which case they commonly observe the 
areas of distribution of one or more cerebral or spinal nerves ; or 
thev are asvmmetrical in distribution. Thev are usually of circular 



ALBINISMUS. 539 

outline, and may be found upon the scalp, face, nipple, breast, and 
genital and other regions. The hairs found upon such parts are 
equally destitute of normal color, being usually white. Negroes thus 
marked are generally termed " piebald " and the integument similarly 
affected in persons of other races has long been recognized as the 
" pied " or " piebald skin." These blemishes when symmetrical, like 
pigmentary nsevi, exhibit a striking analogy with the symmetrical 
arrangement of the spots, bands, and stripes to be recognized in the 
furs of many of the lower animals. The outline of the patch may be 
abrupt, or it may gradually shade into that of the adjacent integu- 
ment. At times islands of pigmented skin are visible within the non- 
pigmented areas. The changes in these patches during later life may 
be insignificant, or they may individually increase in size with age, 
or even multiply. Earely they regain pigment in later life. In 
no case is there an excess of pigment deposited at the border of the 
patch. 

This condition is practically remediless. 

ALBINISMUS. 

(Lat., alius, white.) 

(Complete Con-genital Leucoderma, Congenital Leukasmus, 
Congenital Achromia, Congenital Letjkopathia.) 

Symptoms.- — The term albinismus is here limited to the congenital 
conditions of achromia induced by universal absence of cutaneous pig- 
ment. 

This deformity is peculiar to individuals known as " albinoes " 
(Kakerlaken; Dondos), isolated instances of this anomaly occurring 
in all races, but more frequently among those having normally a hyper- 
pigmentation of the skin, such as negroes. In the subjects of this 
anomaly the skin has a milky-whitish, transparent, or rosy-tinted 
hue, and is usually of delicate texture ; the hairs are silky and yellow- 
ish, reddish, whitish or snowy-white in color ; the iris transparent or 
pinkish; and the pupil, in consequence of defect of pigment in the 
choroid, is also reddish or pinkish. There are, as a result, nyctalopia 
and heliophobia, with frequent nictitation, pupillary variations, 
and the semblance of myopia. The pinkish hue of the skin in 
these individuals is due only to its translucency and vascularity. 
The defective condition of the pigment is usually unchanged 
throughout life ; but in no other respect, save as to pigment-anomaly, 
does the skin of the healthy albino indicate disease. 

Many persons thus deformed', however, are far from vigorous. It 
has been observed that some albinoes are physically inferior to the 
average of persons of the same sex, both in stature, weight, mental 
activities, and powers of resistance to disease. There are, however, 
numerous striking illustrations of the reverse of this, and we have 
had under observation a number of albinoes in one family in which 



540 PIGMENT ANOMALIES. 

alternations of non-pigmented with normally pigmented children ex- 
hibited no difference whatever in stnrdiness and vigor. Many en- 
feebled albinoes are simply illustrations of the wretchedly unwhole- 
some life of persons imported for exhibition into foreign countries. 

Etiology. — Inheritance is evidently a strong factor in the produc- 
tion of this and similar pigment-anomalies. Alternations in birth of 
white and of black children in one family are recorded, yet it is un- 
usual to find albinoes in two succeeding generations, an occurrence of 
no great rarity in inherited affections. 

The condition is remediless ; it has been suggested that transfusion 
with the blood of a vigorous black-skinned African might modify the 
color-characteristics of the pure albino. 

In MarcyV report, a black father and mother had first two black 
male infants, then two female albinoes, then a black female child, 
and, lastly, a male albino. We recently exhibited in our clinic twin 
albinoes, children of Irish parents. In Sym's 2 cases, the first, third, 
fifth, and seventh children were albinoes. 

VITILIGO. 

(Lat., vitium, a blemish.) 

(Acquteed Leucoderma, Leukopathia, Leukasmus, Achromia, 
Piebaed Skin.) 

Vitiligo is an acquired cutaneous achromia, exhibited in single or 
multiple, variously shaped and sized patches, unaccompanied by 
textural changes in the skin, and usually bordered by tissues exhibit- 
ing pigmentary excess. 

Symptoms. — This disorder of the pigment of the skin is one ob- 
served among the several races, often in the negro, and not rarely 
among those of Aryan descent. It commonly occurs without the 
slightest appreciable disorder, subjective or objective, save that be- 
trayed to the eye in the color-changes of the skin. One or several 
rounded, oval or very irregularly shaped, smooth, and well-defined, 
pale or milky-white lines, streaks, or disks appear, often bordered 
at the periphery by an integument which assumes a light- or dark- 
brown or chocolate shade, this hue being by contrast most noticeable 
immediately at the contour of the patch, and imperceptibly fading 
into the normal color of the outlying integument. These patches are 
neither elevated above nor depressed below the general level of the 
integument. The patches may be few, numerous, or in rare in- 
stances coalesce to the point of producing a generalized albinism. 
The hairs or lanugo-filaments growing from the affected area may 
or may not be blanched; most commonly they are, a condition par- 
ticularly conspicuous when, as is not rarely observed, a vitiliginous 
disk extends from the back or the side of the neck well into the 

1 Amer. Jour. Med Sci., 1839, xxiv., p. 517. 
- Trans. Lond. Ophthal. Soc, 1891, xi., p.' 218. 



VITILIGO. 



541 



scalp, in which case the outline of that portion of the scalp in- 
volved is clearly denned by the whitened pilary growth. Lesser 
describes a condition termed by him Peliosis Circumscripta Acquisita, 
in which the hairs were thus blanched in a single area of an unaf- 
fected scalp, an observation confirmed in many cases. 

The most common seats of the disease are the face, the neck, the 
backs of the hands, the genitals, the trunk, and the extremities. 
Upon the backs of the hands the disfigurement is usually more con- 
spicuous in summer than in winter, a circumstance which probably ex- 

Fig. 92. 









' 


"*- s xi 


*.^P -A 




, ~ ■ ,-, ..:■•.; 


# 



(Copyright, 1900, G. H. Fox.) 

Vitiligo. (G. H. Fox's Atlas of Skin Diseases.) 



plains the reported instances of recurrence and total disappearance of 
the disease in successive years. The changes are due to a deepening 
of the pigment in the normal areas on exposure to the sun, thus mak- 
ing a more striking contrast with the non-pigmented spots. 

The course of the affection is exceedingly slow ; there may be for 
years no apparent extension of any involved area or the achromia 
may progress by peripheral extension and by the coalescence of rela- 



542 PIGMENT ANOMALIES. 

tively small affected areas until a large portion of the trunk, the 
thighs, the buttocks, or other part of the body is involved. Hall 1 
reports the case of a dark mulatto who became "perfectly white," 
with the exception of a patch on the chin. Levi 2 reports three in- 
stances of total disappearance of pigment. Hardaway, 3 Simon, 4 and 
Stelwagon 5 also report cases in which the loss of pigment was general 
or complete. It not infrequently happens that the loss of pigment is 
so extensive on the face, hands, and other regions that the eye of the 
observer is struck no longer by the unusual whiteness of the involved 

Fig. 93. 




Vitiligo. 

patches, but this whiteness being generalized and apparently that 
proper to the person, the remaining normal areas appear to be hy- 
perpigmented. Patients with vitiligo frequently suppose that the 
whitened areas are normal, and the darker ones abnormally pig- 
mented. Patients of lymphatic temperament and blonde complexion 
(often women in early adult life) occasionally will apply to a physi- 
cian for relief of dark patches on the skin of the face. Examination 
discloses faint lines, ribbons, or streaks of pigment about one or both 
cheeks, the temples, or the lips. But careful scrutiny recognizes an 
undue whiteness of the skin, with exceedingly faint and irregular 
outline near or next to those pigmented portions of which complaint 
is made. In these cases care is necessary to make a diagnosis between 
vitiligo and chloasma. 

The disorder shows a tendency to spread, though as a rule a limit 
is reached eventually, beyond which the atrophy does not progress. 
In exceptional cases the parts which have lost pigment again 
acquire it. 

1 Louisville Med. News, 1888, x., p. 148. 

2 Receuil de Mem. de Med. de Chir. et de Pharm. mil., 1865, p. 193. 

3 Manual Skin Diseases, 2d ed., p. 280. 
* Deutsch-Klinik, 1881, p. 399. 

Amer. Jour. Med. Sci., 1885, xc, p. 168. 



VITILIGO. 



543 



The patch of skin from which the pigment has been removed is 
often exceedingly sensitive to the action of solar rays and to externally 
applied irritants chemical and other. It then exhibits a peculiar dif- 
fused pinkish shade of color occasionally with production of reddish 
papules, the disappearance of which never is followed by the pig- 
mentation occurring in normal skin after marked hyperemia. 

In vitiligo, aside from the dyschromia, the skin is normal. Pa- 
tients affected with vitiligo should be subjected to a careful general ex- 
amination as there is usually a deviation from the normal in some or- 

Fig. 94. 




Vitiligo. 



gan of the body. In children it may occur as early as the fourth 
year of life (Crocker) and although not generally recognized in such 
cases it usually follows scarlet fever. It is especially apt to develop 
on lichen planus, scleroderma, syphilis, and leprosy. 

In women it is most frequently observed as a manifestation of the 
menopause, it occurs in nervous exhaustion, myxcedema, asthma, in 
Graves's 1 disease even when the symptoms are not well marked, and 
also in association with some minor affections. A morbid mental 
condition, especially in women of middle life, often is produced 
when the disfigurement involves the facial region. 

Etiology. — Although the etiology of the disease is unknown it 
may best be explained as stated by Gaucher 2 on the assumption that 
it is caused by toxines derived from some distant hidden or apparent 

1 Cf. Dore, B. J. D., 1900, xii., p. 353; Hyde and McEwen, Amer. Jour. Med. 
Sci., 1903, cxxv., p. 1000. 

2 Annales, 1902, s. iv. ; iii., p. 1113. 



544 



PIGMENT ANOMALIES. 



focus of disease. The disorder is of more frequent occurrence than 
dermatological statistics tend to show. Many persons who are the 
subject of vitiligo of an inconspicuous part of the body do not con- 
sult a physician with regard to the nature of the disease, as it occa- 
sions no physical distress. 

Pathology. — The pigment normally present in the deep rete-cells 
is absent in vitiligo-spots, but greatly increased and deepened at the 
borders of the areas. In the corium are cells which contain pigment- 
granules. These are especially numerous at the margins of patches, 
where blood-vessels, follicles, and glands are surrounded by many 



Fig. 95. 




Vitiligo. (Douglass W. Montgomery.) 



oval, stellate, and branched pigment-cells. The probable nature 
and origin of these cells are considered under Chloasma. Leloir and 
Chabins have demonstrated atrophy of the subdermal nerves in 
patches devoid of pigment. Other changes in the skin have not 
been noted. 

Diagnosis.— The diagnosis is based on the achromia, with usu- 
ally a hyperpigmented border, and the absence of other symptoms. 
In all typical cases the recognition of the disease is facile. The sev- 
eral chloasmata are distinguished by their failure to exhibit the dis- 
tinctly outlined circular border of the characteristically developed 
vitiligo patch. Much attention has been given to the distinction 
between vitiligo and the leucodermatous patches of anaesthetic lepra, 
but a studv of the macular lesions in the disease last named reveals 



VITILIGO. 545 

distinctly the presence of a systemic disorder with anaesthesia of the 
affected areas. Morphoea is a disorder of the skin accompanied by 
infiltration of the integument while vitiliginous patches are solely 
distinguishable by reason of the color-changes. The color, surface- 
scaling, and localization of tinea versicolor usually serve for its recog- 
nition, and the parasite always can be recognized by the microscope. 

Treatment. — Much chagrin will be saved both physician and pa- 
tient by practically regarding vitiligo as not amenable to treatment. 
Patients occasionally recover while under treatment, which, how- 
ever, has contributed generally but little to the result. Arsenic and 
iron internally, recommended highly by some writers, have failed re- 
peatedly to accomplish any appreciable results as regards dyschromia. 
By efforts directed to the removal of the hyperpigmentation in the 
border of the achromic patches the disfigurement may be lessened 
somewhat. The method of arriving at this end is described in con- 
nection with the treatment of chloasma. It is possible that further 
experimentation with hypodermatic injections of pilocarpine, that 
have in a limited number of cases been followed by disappearance of 
the disease, may warrant a less unfavorable view of the results of 
treatment. Savill 1 reported a return of normal color in vitiliginous 
patches to which he had applied pure carbolic acid. D. W. Montgom- 
ery 2 reports a case of vitiligo in which several applications of the 
Finsen light were followed by restoration of the normal pigment. 
We have tried the method in four cases with negative results. 

Prognosis. — The health of the subject of the malady is not im- 
paired. The disease is practically incurable, progressing usually 
until it has obtained a maximum of development; and then, as a 
rule, remaining unchanged throughout life. 

1 B. J. D v 1898, x., p. 99. 
2 J. C. D., 1904, xxii, p. 17. 



35 



CLASS VI. 
NEW-GROWTHS 



CICATRIX. 

(Scae. Fr., Cicatrice; Ger., ]STaebe.) 

A cicatrix is a new-formation of the skin, replacing connective 
tissue which has been lost by traumatism, by ulceration, or by some 
other pathological process. Most cicatrices, as, for example, those 
following the ulcerations of syphilis, the operations of the surgeon, 
or the dermatitis produced by a severe burn, are reparative in char- 
acter. 

Scars vary greatly in shape, size, color, and other features. They 
may be smooth, glossy, shining, scaling, dull whitish in color, or pink- 
ish from vascularization of the surface. They may be linear, fan- 
shaped, circular, corded, ridged, dotted, crateriform, or tumor-like. 
They may be raised above the skin, on a level with it, or depressed 
below it. They may be deeply attached to periosteum or to bone, or 
readily be movable over the panniculus adiposus. They are of deeper 
color when young, and increase in whiteness with age. They are 
unprovided, as a rule, with hairs, or with coil- or sebaceous glands. 

The most insignificant cicatrices are those resulting from clean, 
incised, and punctured wounds and lesions of similar grade. Certain 
peculiarities of cicatrices are seen in special disorders in which they 
are produced. Circular, oval, reniform, horseshoe-shaped, S-shaped, 
and figure-of-eight-shaped scars, thin and flexible, are characteristic 
of syphilis. The cicatrices of variola, zona, and ecthyma are slightly 
different each from the other, though all are of small size and de- 
pressed. Those of tuberculosis and dermatitis calorica of severe 
grade are exceedingly irregular and often corded. 

Hypertrophy of cicatrices is the condition elsewhere described as 
keloid. Here there is a tumor-like development of the cicatrix, form- 
ing a ridge, button, knob, indurated fold, or puckered and irregularly 
circumscribed, whitish or reddish lesions. In certain individuals 
these lesions may follow almost every traumatism and destructive 
process to which the integument is liable. 

A case of cicatrix undergoing involution has been described by 
Dyce Duckworth, in a man (aged fifty) who suffered from rheumatic 
fever on two occasions, ten years before the date of report. This 
patient had pericarditis, and was blistered over the precordia. Erne 
months afterward lines of cicatricial growth began to form in the 
scar left by the blister, and they rapidly extended ; in two years' time 

547 



548 NEW-GBOWTES. 

they were still enlarging; in seven years some subsidence was noticed, 
and, when exhibited ten years after their first formation, involution 
was markedly progressing. This case illustrates the frequent origin 
of scar-tissue, its common occurrence over the sternum, and the fact 
of the subsidence of the new-growth in the course of time. 1 

Keloid-like cicatrix of the cheeks following acne is far from un- 
common. Its lesion is usually smoothed down in the process of time, 
after the disappearance of the sebaceous gland-disorder, until the de- 
formity is lessened greatly, and often scarcely noticeable. Colloid 
degeneration occurring in scar-tissue and producing lesions which 
clinically resemble those of xanthoma is described by Juliusberg 2 
and Dubendorfer. 3 We have seen this condition twice — once in the 
scars of syphilis and once in those of tuberculosis. 

Etiology. — The formation of cicatrix is always preceded by 
destruction of at least a portion of the papillary body of the corium. 
This loss of tissue may be due to various causes: trauma, burns, 
ulcers, atrophy caused by pressure of new-growths, etc. Hypertro- 
phied cicatrix may result from slight but continued or frequently 
repeated irritation of a healing surface, the repair of which is thus 
greatly delayed, but it occurs chiefly in the form of cicatricial keloid. 

Pathology. — Histologically, scars are made up of connective-tis- 
sue bundles which interlace in all directions with great irregularity. 
In young scars the fibres are finer and the tissue is vascular, but as 
the scar grows older the fibres usually become coarser and contract 
and the vessels disappear. There is complete absence of hair-fol- 
licles, glands, and furrows of normal skin. The scar-tissue proper is 
covered with a very thin epidermis, and Heitzmann claims that shal- 
low and irregular papilla? are always present. Other observers re- 
port in scars an entire absence of both papilla? and rete-pegs. 

Diagnosis. — The distinction between hypertrophied cicatrix and 
keloid is one chiefly of degree and needless from a practical point of 
view. 

Treatment. — The resources of modern surgery are to be trusted in 
the production of laudable cicatrices when all antiseptic precautions 
are observed. The treatment of pathological conditions likely to be 
followed by cicatrices is the treatment largely of the special disease in 
which such loss of tissue occurs, e. g., the ulcer left by a degener- 
ating syphilitic gumma of the skin. An irregular or disfiguring 
cicatrix may be excised if there be sufficient tissue to permit direct 
union on either side. Skin-grafting may be employed after excision 
of larger scars. Radiotherapy has given good results in some cases, 
producing, through absorption of the tissue, a softer, thinner, and 
smoother scar than the original. Injections of thiosinamin have been 
successful in a few instances. Further details are given under treat- 
ment of keloid. 

'Brit. Med. Jour., 1881, ii., p. 597. 

3 Archiv, 1902, lxi., p. 175 (with bibliography of colloid degeneration, and of 
pseudoxanthoma) . 

3 Ibid., 1903, lxiv., p. 175. 



PLATE XXIV 




Keloid in the Negro. 



KELOID. 549 

KELOID. 1 

(Gr., xn^V, a crab's claw.) 
(Cheeoid, Kelis. Ft., Cheloide, Cancro'ide ; Get:, Knollen- 

KEEBS, AlIBERt's KELOID.) 

Keloid is a neoplasm of the derma usually following trauma, de- 
veloping as one or multiple fibro-cellular elevations of the skin, irreg- 
ularly shaped, smooth or corrugated, whitish or reddish in hue, and 
resembling a thickened and hypertrophied cicatrix. 

The term keloid, first given to the disease by Alibert, should be 
restricted to it exclusively. The so-called " keloid " of Addison is 
known to-day more properly as scleroderma. 

Authors have described two varieties of this disease : the " true," 
" spontaneous," or idiopathic form ; and the " false," " spurious," or 
cicatricial form, which develops in the scar produced by a previous 
traumatism. 

There is no anatomico-pathological separation between the two. 
Cases of so-called " spontaneous keloid " are instances of develop- 
ment, of the growth in regions of pressure, contusion, traction, or 
slight traumatisms that have not been recognized, such as the wounds 
inflicted by mosquitoes. Eeiss 2 reports a case in which more than 
two hundred small keloid growths appeared over the chest and flexor 
surfaces of the extremities of a healthy girl, twelve years of age, 
without preceding cutaneous lesions or traumatisms. 

Symptoms. — The new-formations of this disease are dense, gen- 
erally elastic nodules imbedded in the corium or projecting above 
the level of the skin and firmly attached to it. They are usually 
slow of evolution, and, having once attained full development and 
assumed one of the several shapes which they affect, often persist for 
a lifetime. These forms are whitish or reddish, globular or semi- 
globular nodules, buttons, or plaques with roundish or ovoid outline ; 
linear elevated stria?, bands, ridges resembling cords, ribbons, or tapes, 
in irregular outline and disposition ; or combinations of two or more 
of these figures. A common form over the sternum and in other situ- 
ations where the development of the growth in every direction is not 
impeded, is that of a larger central mass with two or more diminish- 
ing and declining prolongations bearing a remote resemblance to the 
body and claws of a crab. The lesions vary in size from that of a 
small pea to that of a large plate, the largest including the outlying 
points of the limbs or radiating ridges. Over them the skin is red- 
dish or whitish in color, smooth, hairless, and occasionally hyper- 
sensitive to pressure and heat. Often blood-vessels traverse its sur- 
face. The growth at times is also the seat of spontaneous pain. 

The most frequent site of the disease is the anterior surface of the 

1 For review of subject, with bibliography, see Reiss, Archiv, 1901, lvi., p. 323 ; 
Berliner, Monatshefte, 1902, xxxiv., p. 321; and Tschlenow, Zeitschrift, 1903, x., 
p. 120. 

2 Loc. cit. 



550 



XZlf'-GItOWTHS. 



chest, but it La observed also upon the face, neck. cars, breast, bands, 
between the scapulae, and on the extremities (Fig. 96). Keloid is 
also seen upon the penis of the negro. It is far more common in the 
colored than in the white races. Though frequently multiple, there 
are rarely more than a score of these growths visible at one time 
upon the skin of one person. 

The overlying integument at Times may be uncolored wholly in 
the white races, and (lead whitish in color or even blackish among 
negroes. At other times die surface is not merely pinkish or red- 
dish, but is vividly red in hue. The color is produced by vascu- 
larity of the gmwth. The subjective sensations aroused are com- 
monly trifling or inappreciable; at other times the growths are the 
seat of severe pain or of burning. The usual course of the disease 

Fig. 96. 




is toward the production of tumors of a medium size, after which few 
changes are to be recognized. Involution and complete disappearance 
are rare. These results, however, have been secured in a few cases. 
Cicatricial Keloid ( Scur-keloid, Hypertrophic Scar, Hypertrophic 
Cicatrix) is a term employed to denote that the lesion has been pre- 



KELOID. 



551 



ceded by scar-formation, due either to disease or to injury. It thus 
follows the lesions of zoster, variola, and syphilis, as also traumatisms 
of all sorts, including those made by surgical operations and accidents. 
The presence of a large number of small scattered keloids suggests to 
the mind of the experienced clinician the frequent use of the hy- 
podermic syringe, as keloids form at the point of puncture of the 
hypodermic needle. 

It is not every scar even in susceptible individuals which becomes 
hypertrophic. The tumors, as a rule, spring directly from scar-tissue, 
and after reaching a maximum of development do not surpass the 



Fig. 97. 






%t 



Hypertrophic scars (keloid) following burn. 

limits of the original lesions; at times, however, the growths slowly 
develop at a distance from the original site of injury or disease. 
Scar-keloid often is found as a firm nodule in the lobe of each ear 
among women, after piercing the ears for the insertion of earrings; 
it is seen also not rarely as a result of burns, whether produced by ap- 
plication of caustic agents or of heat. 

Lesions of this kind rarely develop symmetrically. They may be 
counted at times by the hundred ; commonly but one or two are seen 
in one person. They may persist after reaching a maximum develop- 
ment, or spontaneously, wholly or in part, disappear ; or ulcerate ; or 



Acne-keloid (see Dermatitis Papillaris Capillitii) is a term de- 
scriptive of acneiform lesions over the nucha and scalp, the symp- 
toms including those related to changes in the hair-pouches and con- 



552 



XEW-GEOWTHS. 



tained hairs. Acne, both of the face and back, of severe grade and 
unusual persistence, often leaves minute multiple and somewhat de- 
forming keloid growths where the sebaceous glands have been impli- 
cated most seriously. 

Etiology. — The origin of the disease is exceedingly obscure. 
Neither age, sex, nor previous disorder of the skin seems to have any 




Hypertrophic scars (keloid) following burn. 

bearing upon its production. It is seen in remarkably vigorous per- 
sons ( more often in the negro race), but also in those who are weakly. 
The very young and very old are more rarely affected. 

Though not yet demonstrated, it is probable that eventually some 
varieties of keloid will be recognized as examples of cutaneous para- 
tuberculosis, the predisposition to the development of the disease in 
sites of slight traumatism being related to the toxines furnished from 
a distant focus. The race in which its lesions are most often and 
most voluminously displayed is exceedingly prone to tuberculous in- 
fection; and the frequent recurrence of the disease after surgical ex- 
cision and the peculiar lupoid aspect of certain keloid lesions are 
strikingly suggestive. 

Pathology. — According to Langerhans, Warren, Kaposi, and 
others in all cases of keloid the papillary layer of the corium and the 
interpapillary projections of the rete downward are intact, the new 



KELOID. 553 

formation being strictly limited to the middle and lower portions of 
the corium, in which there are numerous whitish, tendinous fibres of 
connective tissue, dispersed for the most part parallel with the surface 
of the rete. In cicatricial keloid these observers find a partial or com- 
plete absence of the papillae and interpapillary processes. Babes, 
Crocker, and others, on the contrary, find that the papillae and rete 
may be normal, modified, or absent in either form. Lymph-vessels 
with proliferated endothelium, compressed by longitudinal growth 
of the fibres, pass in both vertical and horizontal planes, for the most 
part remaining pervious. There are few spindle-cells and nucleated 
cells. Blood-vessels are few in the centre of the tumor, but are nu- 
merous at the border and in the loose connective tissue surrounding 
the growth. For some distance beyond the tumor the adventitia of 
the vessel shows a small-cell-growth which probably develops later 
into spindle-cells and fibres. These, with the included tissue of the 
corium, form the keloid. The sebaceous glands and coil-glands, hair- 
follicles, and muscles are pushed to one side by the new growth and 
often are atrophied. 

Diagnosis. — The situations of the lesions of keloid, often over the 
sternum, the infrequency of multiple tumors, its claw-like prolonga- 
tions and yellowish- white, reddish, or grayish-white color, all point to 
the nature of the disease. 

Treatment. — The most satisfactory treatment for keloid and hy- 
pertrophic scars is found in radiotherapy. Ullmann, Taylor, Pusey, 1 
and others report instances in which a keloid or thick scar has been 
removed wholly or in part by the use of the arrays. In more than a 
score of cases of true keloid and of hypertrophic scars, in which we 
have tried the method, the improvement has been altogether satisfac- 
tory. In 2 instances in which the scars, due to burns from steam, 
were extensive and very disfiguring, fourteen and sixteen treatments 
respectively produced a gradual disappearance during the following 
six months, of the entire thickness of the growth, leaving soft, pliable 
scars. Removal of keloid by cauterization and excision is not to be 
practised, as the growth commonly does not fail to reappear. Vidal 
successfully employed multiple linear scarifications. Various stim- 
ulating applications may also be made with a view to promote re- 
sorption, such as the spirit of green soap, iodated glycerine, iodine in 
ointment and tincture, and mercurial, salicylated, and lead plasters. 
The employment of these remedies is subject to the danger of stimu- 
lating the growth to greater activity. Where there is pain anodyne 
unguents may be employed topically, such as freshly prepared bella- 
donna plaster, or ointments of belladonna, stramonium, and opium. 
By far the most elegant of these, and the one which also is capable 
of producing an alterative effect, is the oleate of mercury and mor- 
phine. Laurence 2 obtained good results by scarification followed 
for several weeks by moderate pressure produced with adhesive plas- 

1 The Eontgen Eays in Therapeutics, p. 558. 
- Brit. Med. Jour., 1898, ii., p. 151. 



554 NEW-GEOWTES. 

ter. Ularic and others report successful destruction of keloid with 
injections of 5 to 20 per cent, solutions of creosote in olive oil. Elec- 
trolysis has given good results in a few cases. Tousey, Newton, 
Oocker, 1 Xeisser, and others report excellent results from injections 
along the growths of from 10 to 20. minims (0.6G-1.33) of a 10 per 
cent, solution of thiosinamin in equal parts of glycerin and water, or 
in alcohol. 

Internally, quinine, strichnine, arsenic, and potassium iodide have 
been exhibited with varying success. 

Prognosis. — As regards the general condition of the patient the 
prognosis is favorable. Very rarely there is spontaneous resorption 
of the nodule or tumor. Generally the latter may be expected to 
persist, after full evolution is attained, for an indefinite period of 
time. 

FIBROMA. 

(Lat., fibra, a fibre.) 

(Fibroma Moixttsovm, Von Recklinghausen's Disease, Neuro- 
fibroma.) 

This disease is a developmental defect, manifesting itself by the 
presence of tumors of the skin and other organs of the body; pig- 
mentations of the skin and mucous membrane of the mouth; and by 
defect in the mental development. One or both of the two last-named 
symptoms may be absent. 

Symptoms. — The tumors are usually numerous and scattered 
irregularly over the entire body. They are from pea- to egg-sized and 
vary greatly according to their age and dimensions. In early de- 
velopment they present dome-shaped pea- to bean-sized elevations 
which are softish, semisolid, or pasty, with a normal epidermal 
covering. Later they are cone-shaped, semi-solid formations, some- 
times capped by an opaque summit which presents the appearance of 
a vesicle and which bleeds freely when pricked. Digital compres- 
sion causes these tumors to disappear through a ring in the skin and 
when released they spring back into their normal position. Old tu- 
mors are less gelatinous, are firmer, harder, and mammillated, 
often pedunculated. Small-sized tumors may recede, leaving an 
empty pouch of skin. When egg-sized, the tumors are usually sub- 
cutaneous, and are less lobulated than fatty tumors. When diffuse, 
especially in the face, they draw the skin into extensive folds (fibroma 
pendulum). Occurring about the anus they present folds of tissue 
which resemble the labia minora vulva? and which annoy the patient 
in defecation. They are not painful when touched and they produce 
no subjective symptoms. In a given case tumors of all sizes and in 
all stages of development may be present. When very large, there 
may be a single tumor present, which may be more or less peduncu- 

1 Diseases of the Skin, 3d ed., p. 942. 



PLATE XXV 




Multiple Fibroma of the Back. 



PLATE XXVI 




Fibroma Pendulum. 






FIBBOMA. 555 

lated. The tumors may affect the mucous membrane of the mouth, 
large nerve trunks (sciatic nerve), suprarenal capsule, intestines, and 
other internal organs. Patches of leucoderma, telangiectasia, patu- 
lous orifices of sebaceous glands, comedones, and fatty tumors are not 
uncommon. 

Pigmentations are usually light- to dark-brown colored freckles 
sprinkled over the entire cutaneous surface together with a few large 
patches of pigmentation; jet black points of pigment are sometimes 
observable in the larger areas. The freckles may be discernible 
in the negro. 

Oddo 1 has reported two cases in which there were pigmentations 
of the mucous membrane of the mouth, resembling those commonly 
observed in the mouths of dogs. Weber 2 and a few others have re- 
ported anomalous cases of cutaneous freckles and patches of pigmenta- 
tion which they believe are cases of Von Recklinghausen's Disease. 

Hebra called attention to the low standard of physical and mental 
development of the subjects of the disease seen by him; a fact ob- 
served by many and well illustrated in a case recently presented in 
our clinic, the patient being an exceedingly myopic, poorly nourished 
white male dwarf, whose body literally was covered with fibromata 
from scalp to the feet. 

Etiology. — Yon Recklinghausen's Disease is peculiar to neither 
sex. It cannot be claimed as the disease of any special race but it 
is more common in the negro than in the white race. The disease 
may be present at birth or it may appear at puberty or even in 
early adult life. The most striking fact regarding the etiology is 
its sudden appearance following any severe tax on the system, such 
as the first menstruation, pregnancy, or disease of such severity as 
malaria, dysentery, or pulmonary tuberculosis. It may develop 
in the absence of these predisposing factors. The hereditability of 
the disease is made probable by the observation of cases in which 
other defects of development were present, and also of families where 
several members were afflicted, as well as those in which the disease oc- 
curred in three successive generations. 

Pathology.- — Under the microscope the tumor is seen to be a 
variety of myxo-fibroma ; the cells are spindle-shaped and round, and 
have a marked nucleus and gelatinous protoplasm. They are seen 
when quite young to originate from sebaceous glands, sweat glands, 
or other parts of the derma. As they become older the outer layers 
of the tumors develop into coarse fibrous tissue, while the central 
part remains gelatinous. Von Recklinghausen showed that the tu- 
mors developed from nerve-sheaths and that they actually contain 
nerve-filaments (neuro-fibroma) . 

Diagnosis. — The tumors of molluscum fibrosum are to be distin- 
guished clinically from multiple cutaneous sarcomata by the viola- 
ceous or reddish color of the latter, the absence of pedunculation, the 

1 Annales, 1906, s. iv., vii., p. 803. 

2 B. J. D., 1905, xvii., p. 226. 



556 NEW-GEOWTHS. 

greater tendency to ulceration, and their evidently malignant charac- 
ter. From tubercles of lepra they are differentiated by the entire 
absence of constitutional impairment and their general development 
in far greater multiplicity. The tumors of molluscum epitheliale 
differ in their contents, their superficial location, and in the frequent 
presence of the dark puncta at their summits. 

Neuroma is usually painful; lipoma less frequently multiple and 
pedunculated, and more suggestive, when handled, of a "pillowy" 
sensation to the touch. Warty growths are readilv distinguished by 
their verrucous summits ; and the gummata of syphilis, by the con- 
comitant or prior symptoms of the existence of lues. 

Treatment. — The treatment of large single fibromata is surgical, 
involving the employment of knife, ligature, ecraseur, or galvano- or 
thermo-cauterization. Multiple lesions are often so numerous as to 
forbid such interference. When there is a distinct vice of develop- 
ment or inherited tendency to the disease little can be accomplished 
in the way of treatment. 

Prognosis. — Rarely, one or more of these lesions disappear by 
spontaneous involution. More commonly they persist after their evo- 
lution is completed. Marasmus, tuberculosis, and a fatal result may 
occur. One or several of the tumors may become sources of danger 
from the occurrence in them of an active inflammation with resulting 
degeneration and septicemic consequences. The disease, however, 
does not in many cases shorten life. In general the prognosis of mul- 
tiple fibromata may be regarded as unfavorable. 

FIBROMA SIMPLEX. 

(Acrochordon, Soft Waets. Ft:, Vekrues charnues.) 

This is a term applied to fibroma molluscum when the tumors 
are few in number and of small size. The first appearance of the dis- 
ease sometimes may be recognized as a roundish spot over which the 
-kin is uplifted. It is of a light-pinkish color. The tumor is soft and 
suggests to the touch a thinning of the derma beneath. The tumors 
may undergo involution but this result is more common when the 
patienl is under thirty years of age. Dermatolysis is produced by 
great activity of the growth of one, or fusion of several, tumors, by 
which a flap of skin is formed. 

Some of the tumors, usually in young subjects, suggest, when 
handled, a vermiculous content. The soft and gelatinous quality of 
the neoplasm in early life is believed to be proportioned to the age of 
the subject ; rapidity of development and succulence of structure are 
simply conditions of imperfect evolution, and are not common in older 
patients, in whom the tumors are firmer and grow more slowly. 

When involution occurs after maturity of the lesions has been 
attained the softish contents of the tumors become adherent to the 
cutis above, and the cutaneous atrophy is proportioned to the rapidity 
of development of the growth and the firmness of its structure. Then 



DEBMATOLYSIS. 557 

ensues a purse-like pedunculation of the tumor, produced by en- 
croachment of the skin upon its pedicle, rendering invagination, 
supposably possible before, afterward difficult or impossible. Grad- 
ually thereafter the neoplasm loses its skin-connection. Eventu- 
ally in many cases only fibrous cords are left, evidently attached to 
the connective tissue beneath, the skin-color paling as the vascular 
tension correspondingly diminishes. Soon the dermal foramen closes, 
and the involutive process is at an end. Then empty and wrinkled 
pouches or purses of integument are left, the further shrinkage of 
which produces multiple warty or nipple-like elevations of tissue (un- 
der the microscope recognized as fibrous structures with an epithelial 
envelope), much in color like the virgin nipple or the scrotum of a 
boy. From four months to a year are requisite for the mature de- 
velopment of the tumors, and nearly as long a period for the com- 
pletion of the process of involution. 

DERMATOLYSIS 

(ClIALAZODERMIA, PACHYDERMATOCELE, FlBROMA PENDULUM, Lax 

or Relaxed Skust) 

is a condition which may be congenital, or which, as appears in what 
precedes, may be produced by fibroma and follow involution of its 
lesions. In other cases it is apparently spontaneous and diffuse, 
but then it is probably the result of some preceding condition that 
has been unnoticed. The skin of patients thus affected is in a condi- 
tion resembling that of the young of several of the larger among the 
lower animals (pups of large hounds, etc.), where enormous flaps of 
skin may be gathered up between the fingers and extended a foot or 
more from the underlying tissue. On releasing such folds the skin 
retracts to its former position. The skin in these cases usually is 
thickened, but it may be stretched to a considerable tenuity, as in the 
case of a man lately exhibited who could cover his face with skin 
drawn up from the surface of the chest. The integument may be ex- 
ternally normal to the view or pigmented. It may be the seat of 
molluscous tumors ; and either insensitive or normally sensitive, or the 
seat of painful sensations. Usually all the functions of the integu- 
ment are preserved. 

The anomaly is always partial and limited to either the face (the 
lids), the neck, the chest, the belly, or the genital region. The 
disease may be congenital or acquired. 

Dermatolysis, as thus recognized, is to be distinguished from the 
laxity of skin apparent in the senile condition and after distention 
from the presence of tumors, pregnancy, etc. Usually, however, in 
the last-named group of cases it is the subcutaneous tissues which are 
relaxed rather than to any unusual extent the skin itself (e. g., the 
mammary glands of women of advanced years, and the abdominal 
muscles after distention of the belly). 



558 



NETV-GEOWTHS. 



PARAFFIN PROSTHESIS. 1 

Since injections of paraffin have been practiced by many so-called 
" dermatological institutes" to remove wrinkles, form dimples, and 
otherwise change the natural contour of the face to suit the fancy 
of the patient, many untoward results are annually presented to the 
profession for correction. The proportion of patients who become 
victims of the peculiar new-growths that sometimes follow such in- 
jections cannot be stated, but it appears to be small compared with 
the large number treated. Surgeons have for several years employed 
paraffin, to replace lost tissue. Since Gesuny first injected a quan- 
tity of paraffin, having a melting point of 40° C, into the scrotum 

Fig. 99. 




Paraffin prosthesis (cutaneous and subcutaneous lesions following). 



to replace lost testicles for the purpose of hiding the deformity for a 
candidate who contemplated taking the physical examination for en- 
trance into the army service, surgeons have utilized the method to 

1 Literature: Heidingsfeld, M. F., Histopathology of Paraffin Prosthesis, J. 
C. D., 1906, xxiv., p. 513 (with many references) ; Ormsby. Oliver S., Tumor 
Formations Following Paraffin-Injections, J. C. D., 1907, xxv., p. 277; Williams, 
A. W., Parafinomata, B. J. D., 1907, xix., p. 432. 



PARAFFIN. PROSTHESIS. 



559 



overcome various deformities. It has been used in the correction 
of sphincter incontinence, in hernia, to separate nerve ends, to cor- 
rect cleft palate, and many, facial deformities especially those about 
the nose. It is to the cases where unsightly new growths occur about 
the face following its use, that this chapter is devoted. The follow- 
ing is a description of the clinical and pathological findings in four 
patients we have had under observation and treatment. 

There is commonly a period of time varying from six to fifteen 
months in which the tissues apparently do not rebel at the presence 
of the foreign material ; then the new growth begins. The sites of 
these deformities are usually at the angles of the mouth about the 
chin, near the junction of the wings of , the nose with the face, between 
and beneath the eyes, and on the upper part of the neck. The masses 



Fig. 100. 




Section from tumor induced by paraf&n. Low power showing Swiss-cheese 
appearance and cellular infiltration. 



vary in size from that of ; a.pea to/.a hen's egg and larger. They are 
firm in consistence, attached to the overlying epidermis, and embedded 
deeply in the subcutaneous tissues. They are bluish-red in color, 
at times brownish-red, often covered with dilated blood-vessels; at 
times they appear not unlike keloid. They are as a rule unaccom- 
panied by subjective sensations, but occasionally some discomfort is 
experienced due to the pressure over the bony prominences. When 
occurring near the angles of itthe mouth, the prominence extends into 
the oral cavity, producing 'bulging of the buccal mucous membrane. 
(Edema of varying degree is present in the surrounding tissues. The 
deformity produced in some of these patients is disfiguring to a high 
degree and practically forbids their appearance among their fellows. 
Histopathology.— The tumor is essentially a connective tissue new 



560 



NEW-GROWTHS. 



growth, resembling to a high degree the granulomata. With the low 
power of the microscope it presents a series of oval and round cavities 
not unlike well aerated Swiss cheese, as described by Heidingsfeld. 
These cavities represent spaces formerly occupied by the paraffin 
which penetrated the tissues in numerous fine channels. The larger 
spaces probably were produced by the paraffin having been deposited 
in masses by rupture of the tissue. In addition to the fibrous bands 
and multi-nucleated cells groups of connective-tissue cells are found. 
It appears probable that owing to the highly vascular tissue in these 
areas, the foreign material is not incapsulated to such a degree as 
when deposited in the purely fatty tissue, such as occurs when used 
in some of the regions referred to above, where surgeons employ it for 
cosmetic or other purposes. 

Diagnosis. — The lesions resemble keloid and at times even lupus 
vulgaris. The hardness of the growth and the absence of the soft, 

Fig. 101. 






\m 



*Vu *. 






m 




i.»».*w 



Section same as Fig. 100. High power showing giant and other cells. 



apple-jelly, brown nodules of lupus distinguish it from this disease. 
The peculiar conformation, color, and size of the masses, together 
with the history of previous treatment with paraffin serve as distin- 
guishing features of the disease. 

Treatment. — Complete 1 excision surgically, followed by radiothe- 
rapy has given best results. The paraffin must be totally removed 
or recurrence happens. Many other methods have been tried without 
success. 

Prognosis. — Sufficient time has not yet elapsed to determine the 
result in an untreated case. It seems probable that malignant de- 
generation would not result. The logical outcome would most likely 



LIPOMA. 



be the ultimate casting off of the affected tissue by secondary infection. 
The deformity is intense in some cases and causes the patient much 
suffering and remorse. 

LIPOMA. 1 

Fatty tumors occur in the corium and subcutaneous tissues and 
viscera and are composed of fat cells similar to those found normally. 
It is to those growths occurring in the corium and subcutaneous tis- 
sue that this chapter is devoted. 

Symptoms. — These tumors may occur singly or as diffuse masses. 
The commonest sites are in the subcutaneous tissue over the shoul- 
ders and back. They also occur in the neck both anteriorly and pos- 
teriorly, in the breast, gluteal region, and rarely on the face, scalp, 
scrotum, and labia. They may be small and flat, or nodular and lob- 

Fig. 102. 




Lipomata (fatty neck^. 

ulated, and vary in size up to that of a man's head. As a rule the 

base is broad, but at times a pedunculated tumor is formed by the 

weight of the mass narrowing its base. The skin over the tumors is 

1 Cf. Lexor-Bevan, General Surgery, pp. 796-805. 

36 



562 NEW-GROWTHS. 

usually normal in color or slightly pigmented, and may be normal 
in thickness. The lobulated condition which is characteristic of 
these growths may he evident to the eye when they occur near the 
surface. Aja a rule no Buhjective sensations are present, but at times 
through pressure on the nerves some pain is experienced. Second- 
ary changes at times occur in the larger tumors such as calcification, 
ossification, cedematous changes, and liquefaction — oily cysts are thus 
sometimes found. The skin over the growth may necrose when 
secondary infection occurs, producing putrefaction. 

That these tumors, though composed of fatty tissue similar to the 
normal, are independent of the general nutrition is shown by their 
persistence in wasting diseases (Virchow). They usually grow 
slowly and cause little inconvenience, but the small multiple and sym- 
metrical variety often develop rapidly. 

Etiology and Pathology. — They are rarely congenital and usually 
develop between the ages of thirty-five and fifty years, and occur most 
commonly in the female sex. They are composed of groups of fat 
cells which are slightly larger than the normal, held together by a 
capillary network forming small lobules. These are not so distinct 
as in normal fatty tissue but are united by connective tissue trabec- 
lre into lobes and differently shaped masses. These tumors are en- 
closed within a connective tissue capsule. The lobules are said to 
" bear the same relation to the nutrient artery as grapes do to the 
stem upon which they grow." 

Diagnosis. — The important points in diagnosis are the position 
of the tumors, their slow growth, mobility, lobulation, and consis- 
tency. 

Treatment. — The treatment consists in complete extirpation by 
surgical means. 

Prognosis. — They are benign and do not recur after complete ex- 
tirpation. They commonly grow to a given size, then remain sta- 
tionary for years. 

ADIPOSIS DOLOROSA.1 

(Dekcum's Disease.) 

This disease is commonly classed as a sub-variety of obesity and 
is briefly referred to here for the reason that in some particulars 
the lesions resemble lipomata. It is a " disorder characterized by 
irregular symmetrical deposits of fatty masses in various portions of 
the body preceded by or attended with pain." It occurs near middle 
life and in woman. The fatty deposits may occur as large masses 
which are soft in consistency. The hands, face, and feet are exempt. 
Its true nature is unknown. The neuralgic pains associated with 
fatty deposits are characteristic. Thin 2 describes two forms of multi- 

1 Dercum, Amer. Jour. Med. Sci., 1892, p. 521. 

2 P. Thin, Adiposis Dolorosa and Painful Symmetrical Lipomata, Monatshft., 
1903, xxxvi., p. 281 ; abstr. J. C. D., 1903, xxi., p. 292. Osier, Modern Med., 1909, 
vi., p. 570. 



NEUBOMA. 



563 



pie painful lipomata which he believes are closely related but not 
identical. 

NEUROMA. 1 

(Gr., vevpov, nerve.) 

(Tumor op the ISTerves. Fr., jSTevrome ; Ger., Neurom.) 

Neuroma is a new-growth consisting of one or several tubercles 
developed in the skin and composed of elastic, fibrous, and connective 
tissue with fibres of nerves. 

Symptoms. — The description appended is a summary of the symp- 
toms detailed in the reports of Duhring, 2 of Rump, 3 and of Kosinski 4 
of cases of neuroma affecting the skin primarily. 

The patients were all men of middle life or advanced years, who 
exhibited upon the shoulders, arms, thighs, or buttocks numerous dis- 
seminated and defined, pinhead- to hazel-nut-sized, spherical or oval 

Fig. 103. 




Neuroma of the skin; external appearance. (Duhring.) 

nodules or tubercles. They were either painful, or painless at the 
outset and painful later. In Rump's case, which was a sample of the 

a For a review of the subject, with full bibliography, see Krzysztalowiez, 
Monatshefte, 1903, xxxvi., p. 421. 

2 "Case of Painful Neuroma of the Skin," Amer. Jour. Med. Sci., 1873, Ixvi., 
p. 413; also supplement to the same, with cuts, ibid., 1881, lxxxii., p. 435. 

3 Arch, f . path. Anat. u. Phys., 1880, Ixxx., p. 177. 

4 Centralbl. f . Chir., 1874. 



564 



XEW-GliOWTIIS. 



false neuroma of Virchow ( fibroid tumor of the nerve), there was no 
pain throughout the course of the disease. 

The nodules were not arranged along the tracts of nerves; were 
immovable, dense, and elastic; were fixed in the corium and extended 
below it. They were purplish or pinkish in color; and the skin be- 
tween them was unaltered, or like that enveloping the lesions, dry, 
uneven, and desquamative. The tubercles were both tender and 
painful, the pain being excruciating, paroxysmal, usually lasting in 
Duhring's patient for an hour, and radiating. It was aggravated by 
temperature-changes, mental emotion, and movement. 

Pathology. — These tumors are composed of a mixture of fine con- 
nective tissue with medullated and non-medullated nerve-fibres; and 
should properly be called neuro-fibromata. Sections of the growth in 
Duhring's ease showed anatomically a connective-tissue stroma, inter- 
woven with fibres for the most part lying parallel with one another, 
each fibre composed of a finely granular central substance surrounded 
by a sheath containing numerous, elongated, oval, somewhat granular 
nuclei. There were also yellow elastic tissue, blood-vessels with thick- 
ened and nucleated walls, and about the latter lymphoid, cell-like 
bodies. There was entire absence of unstriated muscular and fibrillar 

Fig. 104. 




Microscopic structure of neuroma. (Duhbing.) 



connective tisue. The specimen represented the true amyelinic neu- 
romata of Virchow. In Kosinski's case non-medullated nerve-fibres 
and connective tissue were also discovered. In both cases exsection 



MYOMA. 565 

of a portion of nerve (brachial plexus, of the one ; and small sciatic, 
of the other) was followed by considerable diminution of pain and 
almost entire disappearance of the growths. In Rump's case, which, 
as stated above, represented the nbromated and so-called fibro-nu- 
cleated tumors of Virchow, the nodules were strung upon the same 
nerve, " like beads upon a rosary," and were similarly displayed upon 
its branches. Spinal, cerebral, and sympathetic fibres were all in- 
volved. 

Duhring, in commenting upon these rare cases, calls attention to 
the distinction between purely cutaneous lesions and the generally 
solitary, movable, and "painful subcutaneous tubercle." 

Knauss 1 reports a case in a girl of eleven years. There were over 
sixty tumors varying in size from a cherry to a hen's egg. They 
were situated beneath the skin, were firm and elastic, and never pain- 
ful. Histological examination showed them to be composed of medul- 
lated and non-medullated nerve-fibres, and numerous ganglionic nerve- 
cells. 

MYOMA. 

(Gr., fivciv, muscle.) 

Cutaneous myomata are divided by Besnier 2 into two classes: 
simple myoma, or liomyoma ; and dartoic myoma. 

Dartoic Myoma is much more common than is the other form, and 
is of chief interest to the surgeon. It is usually single, though oc- 
casionally multiple, and occurs most frequently on the mammse, the 
labia majora, the penis, and the scrotum. The tumor develops slowly, 
finally attaining a size varying from that of a small nut to that of an 
orange, and may be sessile or pedunculated. In most cases reported 
pain has been slight or absent, though it was marked in a case re- 
ported by Yirchow. Under the influence of cold and local irritation 
the tumor usually contracts or may show a slow vermicular motion. 
Some of these tumors are composed almost entirely of non-striped 
muscle-fibres, others are mixed with other tissues to form a Fibro- 
myoma, an Angiomyoma (Myoma Telangiectodes) , or a Lymphangio- 
myoma. 

Simple Myoma is rare. 3 Its lesions are usually multiple and 
occur most frequently on the upper extremities, affecting chiefly the 
extensor surfaces; but they may occur on other parts of the body. 
They begin as minute round or oval macules or papules which de- 
velop slowly to the size of a small pea or bean, occasionally becoming 
larger. At first readily effaced with the finger, later they become 

1 Virchow 's Archiv, 1898, cliii., p. 29. 

2 Annales, 1880, s. ii., i., p. 25; and Besnier-Doyon translation of Kaposi, vol. 
ii., p. 346, with reference to all reported cases. 

3 For a resume of cases see Crocker, B. J. D., 1897, ix., pp. 9 and 47; Boberts, 
ibid., 1900, xii., p. 115; Morris, ibid., 1901, xiii., p. 8 (a case shown before the. 
London Dermatological Society) ; Marschalko, Monatshefte, 1900, xxx., p. 313 
(with survey of most of the previously published cases) ; and Sobotka, Archiv, 
1908, Ixxxix., p. 352. 



56G XEW-GROWTHS. 

firm and elastic to the touch, are usually limited to one or two regions 
of the body, where they appear in patches without definite arrange- 
ment or grouping, and are pinkish, reddish, or of the color of the nor- 
mal skin. In the beginning the growths are usually insensitive, but 
in most cases after slow evolution become painful on pressure and in 
some instances they are the seat of paroxysms of severe pain which 
occur spontaneously and at irregular intervals. Nearly all the cases 
reported have been in elderly people and in men. Some of the tu- 
mors may undergo involution, but usually they tend to increase in size 
and in number. Histological examination shows that they are lim- 
ited to the derma proper, and are composed chiefly of unstriped mus- 
cle-fibre mixed with some elastic tissue, with a few vessels and nerves, 
and are frequently developed about the hair-follicle. They are prob- 
ably derived from the erector pili muscles. 

In a case under observation multiple pinhead- to large bean-sized 
congenital tumors were situated near the sterno-cleido-mastoid mus- 
cle of a girl nineteen years old. These were exquisitely sensitive to 
pressure, were capable of slight vermicular motion when irritated, 
and examination of the largest, after removal, disclosed smooth mus- 
cular fibres, and, in small proportion, terminal filaments of cutaneous 
nerves. 

Diagnosis. — The diagnosis in well-marked cases is not difficult, 
but in some instances the recognition of the disease must depend upon 
a microscopical examination. Myomata have been mistaken for xan- 
thoma tuberosum, for keloid, for lymphangioma tuberosum multiplex, 
and for neuro-fibroma. The last-named tumors are painful from the 
beginning, and usually develop in the course of a nerve. 

Treatment. — The only successful treatment is by excision. 



OSTEOMA CUTIS. 1 

(Osteosis Cutis.) 

Bony deposits in the skin and subcutaneous tissue may occur sec- 
ondarily in certain diseases such as syphilis, and also as the result of 
trauma, examples of which may be seen in hod-carriers when bony 
new-growths are found under the skin of the shoulder where the 
weighl of the hod falls. Such lesions occurring spontaneously in 
the skin are rare. 

There is now on record a series of five cases and in each the true 
nature of the affection was not discovered until a microscopic study 
was made. These new-growths may be single and localized or mul- 
tiple with more or less generalized distribution. As to origin some 
of the eases point strongly to their being due to misplaced embryonal 

1 Literature: Coleman, Warren, Osteosis of the Skin of the Foot, J. C. D., 
1894, 185-194; Salzer, Osteoma of the Skin, Langenbeck's Archiv, xxxiii., No. 
1 ; Pusey, The Principles and Practice of Dermatology, p. 847 ; Taylor, S., and 
MacKenna, R. W., Liverpool, Osteoma Cutis, J. C. D., 1908, xxvi., 449; Heidings- 
feld, Osteoma Cutis, Archiv, 1908, xcii., p. 337. 



ANGIOMA. 567 

cells, while others, especially those following diseases or produced by 
trauma, etc., may be examples of metaplasia. 

Coleman records the case of a patient six years of age who had a 
plaque of cartilaginous hardness studded with tubercular nodosities 
occupying about one-third of the external plantar surface of the left 
foot. The lesion at that time had existed for two and a half years. 
Upon microscopic examination the growth was demonstrated to be 
osseous. It is interesting to note that this growth recurred after sur- 
gical removal. 

Salzer reported the case of a patient having a nodule in the scalp 
which in the course of four or five years attained the size of a small 
coin. This lesion was freely movable and was excised on account 
of loss of hair in the area. The microscopic study of the case demon- 
strated its true nature. 

Pusey records a case noted by F. G. Harris in which bone forma- 
tion was found in a scar following a laparotomy wound. 

Under the title, Osteoma cutis, Taylor and MacKenna described 
this unusual condition: The patient, a female child aged fifteen 
months, had several bony deposits situated in the skin of the limbs, 
scalp, and trunk. The largest occurred on the thigh and measured 
about one by three quarters of an inch. The overlying skin was pur- 
plish in color and had several millet-seed-sized pearly spots on its sur- 
face. On palpation the plaque was well defined, hard, resilient, and 
elastic. When bent, it would resume its former shape after the 
pressure was removed. Many similar but smaller plaques were dis- 
tributed about the cutaneous surface. Microscopic examination de- 
monstrated the osseous nature of the deposits. 

Heidingsfeld reported finding osseous formation in a pigmented 
nsevus occurring on the chin of a male patient aged twenty-one 
years. In this study numerous bony particles were found and the 
author ascribes the condition to misplaced embryonal rests. 

ANGIOMA. 

(Gt v ayyelov, vessel.) 

Angiomata are divided into those composed of blood-vessels and 
those formed of lymphatic vessels. The former are much more fre- 
quent and variable in character. 

Symptoms. — Blood-vascular new-growths occur in three forms: 
nsevus vasculosus, telangiectasis, and angioma cavernosum. 

Naevus Vasculosus (Ncevus Flammeus, Ncevus Sanguineus. Ger., 
Gefdssmal). — "Port-wine" spots are those vascular anomalies of the 
skin which are either visible at birth or become developed in a brief 
period thereafter. They are usually observed as reddish macula- 
tions of various sizes and shapes. They have a distinct outline and 
are made up of fine blood-vessels which disappear momentarily on 
pressure. The most common location is the back of the neck but they 



568 NEW-GBOWTHS. 

may occur on any pari of the body and on the mucous membrane of 
the lips. In sonic cases they are of a deep violet to port-wine color, 
occasionally tiny are somewhat elevated, and the surface may be 
studded with nodules which are cavernous angiomes. Thrombosis 
followed by gangrene may occur in nsevi of newborn infants and 
result in spontaneous cure. They may exhibit peripheral extension 
and central atrophy. Whitefield mentions a case in which the entire 
cutaneous surface of the abdomen was in an atrophic state surrounded 
by a zone of telangiectases. The most extensive case on record is 
that of Heller. 1 Almost one half of the body was involved. AY here 
extensive this anomaly is usually associated with giant-growth, 2 or 
hypertrophy of the bone and soft parts of an extremity. Osier has 
reported a family form of recurring epistaxis associated with multiple 
telangiectasis of the skin and mucous membranes. Epithelioma may 
develop on vascular nevi. 

Generalized Telangiectasis. — Brocq 3 and several others have re- 
ported cases of this rare affection. It consists of macular areas, 
sometimes slightly scaly, which are usually scattered and sometimes 
large in extent. The plaques are bluish-red in color resembling the 
dorsal surface of a cadaver; hence this condition has been called "ca- 
daver skin." The affection develops at puberty or in adult life. It 
may follow castration in women, scarlet fever, nephritic degeneration, 
and may occur without assignable cause. Hyde 4 has reported cases 
of telangiectasis in exophthalmic goitre, which had been mistaken for 
mycosis fungoides and lupus. Facial telangiectasis also occurs in 
rosacea. 

Only when carefully scrutinized will it be recognized that the af- 
fected area consists of a fine network of capillary vessels and is not 
an erythema as it appears to be at first view. 

Naevus Araneus (Spider Cancer). — This lesion consists of an 
aneurismal dilatation of a papillary loop, producing a pinhead-sized 
red papule which does not always disappear on pressure and from 
which fine blood vessels radiate like the spokes of a wheel. 

Angioma Cavernosum (Tumor Cavernosus). — Cavernous angioma 
is distinguished from the angiomatous lesions described above by the 
peculiarities of its formation. It consists of a dense framework of 
new-formed connective tissue, inclosing loculi or chambers of varying 
capacity, which contain blood, and communicate, not only with each 
other, but with the larger vessels in the vicinity. Whether these 
blood-spaces originate in the fibrous felt-work of the derma which 
later establishes a vascular connection, or in the vessels themselves, 
or whether they are constituted by a mechanical dilatation of such 
vessels in consequence of a new-formed connective tissue in the ad- 
vent ilia, has not been determined. According to Virchow, the lesions 
arise generally from coalescence and dilatation of vessels. Other 

1 Berliner klin. Wochenschrift, 1898, p. 1003. 

2 Annates, 1893, s. iii., iv., p. 233. 

3 Annates, 1897, s. iii., viii., p. 41. 
* B. J. D., 1908, xx., p. 33. 



ANGIOMA. 569 

causes are explained by the earlier formation of a contracted cica- 
tricial tissue by which vascular distortion occurs. (Rindfleisch.) 

Cavernous angiomata are said to be rarely congenital, developing 
soon after birth, and to be both superficial, deep, circumscribed, and 
diffuse. Sometimes they originate from a nsevus or superficial telan- 
giectasis. Often when fully formed they are distinctly encapsulated. 
The diagnosis is between cysts, fibromata, lipomata, and sarcomata. 
The rarity of this affection in dermatological practice may be ex- 
plained by the surgical features of many cases. In five years no in- 
stance of angioma cavernosum was reported in the statistical tables 
of the American Dermatological Association. Post 1 reports a unique 
case in which the tumors were numerous, large, and firm, and re- 
curred after removal. 

Etiology and Pathology. — The causes of the several forms of 
angioma named above are obscure. The symptomatic telangiectases 
are undoubtedly to be explained by obstruction to the circulation occa- 
sioned by the tumor or other lesion to which they are accessory. The 
foundation for the vulgar belief that maternal impressions are respon- 
sible for the so-called " mother's marks " is very slight. The reputed 
resemblance of the latter to various flowers and fruits generally re- 
quires for its recognition a stretch of the imagination. 

Anatomically, these lesions are recognized as due to dilatation and 
new formation of venous and arterial capillaries in the superior por- 
tions of the derma, the vessels of the newly formed plexus freely 
communicating with each other. Generally there is a simultaneous 
new formation of connective tissue constituting the framework of the 
growth, which varies considerably in the different forms of the disease. 
Lobules constituted of coils of capillary vessels are often separated 
by it into distinct masses. According to Heitzmann, the large spaces 
of angioma cavernosum imitate the structure of the corpora cavernosa 
of the penis, and are filled with venous blood, being separated from 
each other by a scanty fibrous connective tissue. 

Billroth states that the new formation has its origin in the vascu- 
lar network surrounding in basket-like forms the fat-lobules, follicles, 
and glands of the skin. Embryonal, vascular growths spring from 
these, and as they multiply and develop are enforced by proliferation 
of fibrous, connective, and muscular tissue. The color depends largely 
upon the preponderance of arterial or of venous capillaries in the new 
formation. 

Diagnosis. — The ordinary lesions of angioma are readily recog- 
nized by their color, size, shape, and obvious vascular constituents. 
Anderson calls attention to the importance of differentiating ence- 
phalocele due to the failure of ossification of the ethmoid and frontal 
bones at the root of the nose. Operations upon such tumors sup- 
posed to be angiomatous in character have resulted fatally. Lobula- 
tion, great distention (when a child is crying), a superficial rather 

1 J. C. D., 1903, xxi., p. 498. 



570 NEW-GBOWTHS. 

than deep and complete vascularization of the smooth and glossy skin 
of the tumor, and a double pulsation, all point to frontal encephalocele. 

Treatment. — Pusey 1 has recently recommended the use of carbon 
dioxide snow in the treatment of vascular and pigmentary nevi. 
This method of treatment is capable of doing harm if not intelligently 
employed. 

Liquid carbon dioxide is obtainable wherever soda fountain sup- 
plies are sold. It is furnished in cylinders. When in use the cylin- 
der is placed in a rack inclined so that the opening is at the lower 
end. As the key is turned the carbon dioxide snow is collected in a 
chamois skin held over the mouth of the cylinder. It is moulded in 
the chamois skin into the desired form and cut with a knife into a 
block one centimeter square in size. 

Applied to the surface of a nsevus with slight pressure while held 
in forceps it freezes the tissue in from five to ten seconds, and thaw- 
ing occurs in twice that length of time, producing a stinging sensa- 
tion. The duration is the most important factor of the treatment. 
If the freezing is not maintained for a sufficient length of time no 
therapeutic affect will be produced ; if too long continued bullae f orm 
on the surface, an eschar is produced which when exfoliated leaves 
a telangiectatic scar more disfiguring than the nsevus. 

Nsevus araneus and small nfevi are best treated by electrolysis. 
One or a set of several fine cambric needles, with their points at the 
same plane, are connected with the negative pole of an ordinary zinc 
and carbon battery of ten or twelve cells. The points of the needles 
are passed quickly into the tissues and there held for a period of 
between ten and thirty seconds, according to the effect produced after 
completion of the circuit, with a current of from one to two milli am- 
peres. The new-growth is thus blanched in the vicinity of the 
needles, this effect disappearing in the course of a few moments. 

Coombs modified the above method, by passing fine silver wires 
through mevus-growths, and connecting the extremities with a Bun- 
sen battery. When the wires are heated the circuit is broken, and 
the ends of the wires are disconnected from the battery and united 
to each other, being left in situ and covered with lint and plaster. 
The current can then be passed repeatedly without reinsertion of the 
wires, and the latter need be withdrawn only when the cure is com- 
plete. 

Phototherapy has proved effective in a small number of cases of 
vascular naevi. The method is preferable to electrolysis when a com- 
siderable area is involved, or when the individual vessels supplying 
or composing the ngevus are not distinctly visible. We have secured 
great improvement with the treatment in two extensive cases of this 

type. 

The method of Sherwell 2 is by multiple puncture with a set of 
fine needles in a holder similar to that described above. These are 

: J. A. M. A., xlix., p. 1354. 
2 Archiv, 1879, v., p. 354. 



ANGIOMA SEBPIGINOSUM. 571 

dipped in a 25 to 50 per cent, solution of chromic acid, and then made 
to penetrate the part to be attacked. The bleeding is readily arrested 
by pressure, and then the patch is covered with several layers of flexile 
collodion. This procedure is of value in circumscribed patches of 
superficial character and relatively limited area. By it one can suc- 
ceed in removing port-wine marks with the result of producing a 
somewhat irregular cicatriform tissue much less disfiguring than the 
original blemish. 

Other methods employed are the ligature when practicable ; punc- 
ture with incandescent needles; topical application of caustics other 
than those named above, such as potassium hydroxide, nitric and car- 
bolic acids, and corrosive sublimate; and total excision, the latter 
being practicable in relatively small growths. Larger growths also 
can be removed and the surface covered with skin-grafts. The gal- 
vano-cautery and the thermo-cautery are both valuable in the destruc- 
tion of capillaries. The old method of multiple vaccination about 
and upon the involved area is sometimes followed by good results, and 
whether in consequence of the retraction of tissue under the influence 
of the inflammation excited, or of the destructive results of the sup- 
puration induced, or of an indefinite caustic effect, is not clear. 

These results may be partly imitated by the production of super- 
ficial pustulation and suppuration through the medium of tartar 
emetic and croton-oil, methods which should be considered clumsy in 
the light of recent successes obtained by more manageable expedients. 

Injections with carbolic acid and ferric chloride should not be em- 
ployed as there is danger of fatal embolism. 

The treatment of angioma cavernosum requires surgical interfer- 
ence. 

Prognosis. — The prognosis in any case of angioma rests upon the 
method of treatment adopted for its removal. In the larger number 
of cases the lesions, having attained a maximum development, persist 
without further pathological change, constituting a deformity rather 
than a disease. Physiological alterations in the color of such lesions 
occur under the influence of changes in the circulation. 



ANGIOMA SERPIGINOSUM. 

(Infective Angioma, IST^vus Lupus.) 

This disease has been described and figured by Hutchinson, 1 
Jamieson, Lassar, Joy, White, and others. It is one of the rarer 
affections of the integument. 

Symptoms. — The elements of each group of lesions are bright- 
reddish puncta, resembling grains of Cayenne-pepper, arranged in 
oval or circular rings which are definitely outlined and are a centi- 
metre or more. in diameter. The "infective satellites" are outlying 
points or patches where the disease is spreading. This extension is 

1 Arch. of Surgery, 1889, i., p. 289, Plate IX. 



572 NEW-GROWTHS. 

usually at the outer border of one of the annular groups of lesions. 
The color varies from a light- to a deep-reddish hue or purple ; tints 
which are due to the vascularity of individual lesions. The color can 
at times be made to disappear on pressure. 

The parts chiefly affected are the shoulder, the leg, the elbow, the 
ear, the arm, the hand, and the chest. The disease may occur in in- 
fancy or adull years. Its evolution is slow, and usually unproductive 
of subjective sensations. Occasionally the tufts of dilated capillaries 
which constitute the reddish points are not grouped in a circinate or 
other special arrangement, but simply irregularly distributed over the 
affected surface. 

Etiology. — The cause of the disease is unknown. In a case under 
our observation in a female infant the lesions developed as a sequence 
of a congenita] naevus of the vulva. Hutchinson has made a similar 
observation. The affection has been noted more often among male 
patients. One case is supposed to have originated in violent muscular 
exercise. 

Pathology. — The disease, being at first but obscurely understood, 
was until recently supposed to be one of the several expressions of 
lupus and was for that reason assigned one of the names given above. 
Examination of tissue removed from a patient whose case was fully 
reported by White, 1 which was in all points typical, reported upon 
also by Darier, Councilman, and Bowen, indicates that the disease is 
an angiosarcoma. Darier describes it as Sarcome Angioplastique 
Reticule. The corium was found well filled with small-cell infiltra- 
tions and these cells had an epithelioid nucleus. There were abun- 
dant proliferation of the endothelium, peri-vascular cellular infiltra- 
tion, and a new formation of vessels. 

Diagnosis.. — The disease is to be recognized by its vascular puncta 
and by their special tendency to grouping and extension through a 
serpiginous process never seen in simple telangiectases, nor in com- 
mon forms of naevus vascularis. 

Treatment. — The treatment is by surgical ablation or destructive 
cauterization. 

TELANGIECTATIC GRANULOMA. 

Kuettner, and also Reitman 2 have described a peculiar form of 
granuloma somewhat resembling angioma serpiginosum. A simple 
granuloma is a proliferation of connective tissue developing from the 
surface of a wound. This disease is a proliferation of endothelial 
tissue. Clinically it consists of a pea-sized growth of endothelial tis- 
sue which bleeds freely and which is surrounded by pin-head-sized 
puncta of bright red color. 

LYMPHANGIOMA. 

In the present state of knowledge on this subject it is not always 
possible to draw sharp dividing-lines between lymphatic new-growths 

1 J. C. D., 1894, xii., p. 505. 
2 Archiv, 19, xci., p. 185. 



LYMPHANGIOMA. 573 

on the one side and simple lymphangiectasis on the other. It is prob- 
able that the two processes often are associated. 1 

Lymphangiectasis, uncomplicated by growth of new vessels, may- 
occur in the superficial or deep lymphatics. When superficial, pin- 
head- to pea-sized, isolated or grouped vesicles form which have the 
color of the normal skin, which disappear temporarily under pressure, 
and which do not break easily, but on rupture give exit to a con- 
tinuous or intermittent flow of lymphatic fluid. Elliott 2 describes a 
case of this kind in which the vesicles bordered old scar-tissue and 
were seemingly identical in character with the lesions of lymphan- 
gioma circumscriptum, but histological examination showed them to 
be formed by simple dilatation of the lymphatic capillaries, due prob- 
ably to mechanical obstruction. 

Lymphangiectasis of the deeper vessels often produces no change 
visible on the skin, and can then only be recognized by palpation, or it 
may be displayed in raised, irregular cords, or in chains of nodules. 
Following injuries or inflammation it may be acute, but usually it is 
chronic, and occurs most frequently on the lower extremities and in 
parts in which the return current of the circulation is in some way 
impeded. The skin may become the seat of soft nodules which may 
rupture and form lymphatic fistules ; but more frequently the greatest 
changes occur in the deeper structures, resulting in elephantiasis, in 
phlegmon, or in lesions of periosteum and bone, the skin of the affected 
region being oedematous, infiltrated, ulcerating, or cicatricial. 

Simple Lymphangioma may occur upon any part of the body in 
the form of circumscribed, elastic tumors made up of enlarged lym- 
phatics which are the result partly of dilatation of previously exist- 
ing vessels and partly of new-formations. The skin over such tumors 
may be unchanged or it may be reddened and thickened. In more 
extensive cases there is hypertrophy of the surrounding tissues as in 
deep-seated lymphangiectasis. Many of the diffuse forms of lymph- 
angioma constitute firm or lax tumors of such size as to be termed 
Elephantiasis Lymphangiectatica or Pachydermia Lymphangiecta- 
tica. These tumors often contain large lymph-filled sacs or lacunas, 
enveloped in hypertrophied muscular and connective tissue, and an 
cedematous integument. Some of the elephantiasic deformities of this 
character are fully as enormous as the extreme distortions of elephan- 
tiasis proper. Upon the tongue the condition is called Macroglossia, 
and upon the lips Macrochilia. 

Lymphadenectasia is a name given by Virchow to tumors usually 
in the axillary or inguinal regions, where the lymphatic vessels in the 
lymphatic glands dilate or multiply so as to form large tumors. The 
lymph-scrotum due to the presence of the filaria sanguinis hominis is 
described elsewhere. 

Simple lymphangiomata may be congenital. 3 Their cause is un- 

1 For review of literature of tlie subject, consult Francis, B. J. D., 1893, v., 
p. 65; and Boberts, ibid., 1897, ix., p. 309. 

2 J. C. D., 1894, xii., p. 137. 

3 Volmer, Archiv, 1903, lxv., p. 343, reports a rare case, with illustrations, his- 
tology, and bibliography. 



574 XEW-GEOWTHS. 

known. It is supposed that they are produced by toxic or other irri- 
tating influences. They are often the seat of a recurrent, circum- 
scribed inflammation of erysipelatous type. Anatomically the lesions 
are found to consist of greatly developed lymphatic vessels and spaces, 
lined with epithelium and enveloped in small-celled connective tissue- 
stroma. The treatment of the larger lesions only is surgical. 

Cystic Lymphangioma belongs to the domain of surgery. It occurs 
in the form of multilocular cysts, usually congenital in origin and 
most frequently situated in the neck. 

Lymphangioma Circumscriptum. 

(Lymphangioma Cavebnosum, Lympiiaxgiectodes, Lymphan- 
gioma Capiixare Vaeicosum, Lupus Lymphaticus. Fr., An- 

GIOME CySTIQUE.) 

This is practically the only form of lymphangioma entitled to spe- 
cial consideration by the dermatologist. It is a rare form of skin-dis- 
ease and is illustrated well in the case reported by Morris. 1 Cases 
have been reported by Torok, 2 White, Francis, 3 Hartzell, Elliot, Gil- 
christ, Brocq and Bernard, 4 Schnabel, 5 and others. 

Symptoms. — The characteristic lesions are small, deep-seated ves- 
icles generally described as resembling frog's spawn. They are usu- 
ally closely crowded in irregularly shaped groups from eight to twenty 
millimetres in diameter with normal skin between. These groups 
have no regular arrangement or distribution. There are sometimes a 
few scattered vesicles about or between the borders of the groups 
which may coalesce to form new patches. There are usually several of 
these groups, but they are confined, as a rule, to one small region of 
the body. The most common sites, according to Francis, who has col- 
lated reports of twenty-eight cases, are on the upper parts of the 
extremities and the mucous membrane of the mouth, pharynx, and 
tongue. In a large majority of the cases reported the lesions occurred 
on the left side of the body. The vesicles are deep-seated with thick 
walls, and vary in size from that of a pinhead to that of a small pea. 
The newer and scattered vesicles may be colorless or have a yellowish 
or pinkish tinge (pachydermatous lymphangioma). The skin over the 
older lesions may hypertrophy and produce growths that are easily 
mistaken for warts, and may even result in decided warty projec- 
tions. Other lesions may be more or less covered with telangiectases 
and vascular dots or tufts which may be present to such an ex- 
tent as to obscure the primary vesicle-formation. When punctured 
the lesions give exit to clear, colorless fluid, in greater quantity than 

1 Internat. Atlas, 1889, No. 1. 

1 Monatshef te, 1892, xiv., p. 169, with critical review of previously published 
cases. 

3 B. J. D., 1893, v., with review of literature. 

* Annales, 1898, s. iii., ix., p. 305 (full discussion of the subject, with review 
of literature). 

B Archiv, 1901, lvi., p. 177, with histology and references. 



LYMPHANGIOMA. 



575 



the vesicles contain which at times may be tinged with blood, the re- 
sult of hemorrhage. 

In some cases the lesions and skin about them become the seat 
of a recurrent inflammation of erysipelatous type/ such as not infre- 
quently complicates other forms of lymphangioma. Probably as a 
result of these attacks of inflammation there are often infiltration, 
thickening, and even true hypertrophy of the deeper layers of the 
skin, forming a sort of local elephantiasis. 

The disease in most cases reported began in early childhood and 
developed very slowly, often remaining stationary for years. In but 
one case has spontaneous involution been reported. 

Etiology. — As the disease usually makes its appearance in infancy 
or early childhood, it is probable that its origin is due to some con- 
genital defect. It has appeared a number of times in connection with 
naevi. It has followed surgical operations, bordering the scars pro- 

Fig. 105. 




Lymphangiectodes (McEwen). 



duced by the operator ; it is possible that such cases are simple lymph- 
angiectases of the capillary vessels due to blocking of the larger chan- 
nels by the scar-tissue. 



1 Cf. White's report, J. 
Twentieth Century Practice, 



C. D., 1894, xii. 
vol. v., p. 687. 



p. 47; also Bowen's article in 



576 NEW-GBOWTHS. 

Pathology. — The vesicles, or cysts, are found on section to be situ- 
ated in the upper part of the corium. These cysts are shown to have 
an endothelial lining and undoubtedly are dilated or newly formed 
lymph-capillaries. Immediately about the cysts and dilated lympha- 
tics in an early uncomplicated lesion Bowen found considerable in- 
filtration of round cells, but no other changes in the corium, while the 
epidermis was slightly thinned. In older lesions there is hypertrophy 
of the epidermal layers, and sometimes of the deeper parts of the cor- 
ium. In other cases there are more or less dilatation and apparent 
new-growth of the blood-capillaries. This change in the blood-vessels 
may be slight or so marked as to form the chief feature of the disease 
both clinically and pathologically. In consequence, confusing reports 
have been made by different observers regarding the structure and 
origin of these growths, many of which seem entitled to the name of 
hemato-lymphangioma. 

Treatment. — The treatment is surgical. The growth may be re- 
moved by excision or with the cautery. Electrolysis has been of ser- 
vice in some cases and should be given trial. In several instances 
the lesions have recurred after complete removal. 

MOLLUSCUM EPITHELIALE. 1 

(Lat., molluscus, soft.) 

(Molluscum Verrucosus, Molluscus Sebaceum, Epithelioma 
Coxtagiosum, Molluscum Coxtagiosum (Bateman), Acne 
vaeiolifoeme (Bazin) . ) 

Molluscum epitheliale, a disease first recognized in 1817 by Bate- 
man under the title Molluscum Contagiosum, presents a more exten- 
sive literature than any of the benign tumors because of the difficulty 
encountered in establishing the fact that it is not a disease of the seba- 
ceous glands. 

Symptoms. — Typical epithelial mollusca are firm, roundish bodies 
averaging in size the dimensions of a pea, and in color varying from 
a waxy whitish hue, nearly that of the integument, to the dark-red 
tint of injected masses. They are either imbedded in the skin or 
project from it as smooth, firm, semiglobular, sessile or pedunculated 
tubercles. Usually a dark-colored aperture can be detected at the 
apex or side of the lesion, from which on pressure, milky and curd- 
like, semifluid contents can be made to exude. Occasionally, inspis- 
sated or even horn-like masses project from these orifices, as though 
forced out by a vis-a-tergo. The disease is rare, and the lesions are 
usually single and isolated, though hundreds may appear upon the per- 
son of one individual. They consist of semifluid collections derived 
from the hair follicle or from percolation between the papilla? of the 
derma. They may be removed by surgical procedures; or be shed 

1 For a complete review of the subject with bibliography and additional re- 
search in the pathology and bacteriology of the disease, see White and Eobey, 
Jour, of Med. Eesch., 1902, vii., p. 255. 



MOLLUSCUM EPITEELIALE. 577 

spontaneously ; or inflame, and result in circumscribed abscess ; or ter- 
minate by ulceration. More often they are insidious and slow of 
development, and may persist for years without producing annoyance 
or subjective sensation. They occur on the face, the side of the neck, 
and the nucha; on the penis and scrotum of men, and the breasts 
and labia of women; on the trunk; on the flexor surfaces of the 
extremities, and the dorsal surfaces of the hands and feet. They are 
most common in children. In consequence of the depression of the 
centre of the little tumors (which Hutchinson has happily likened to 
small pearl buttons) they may suggest the lesions of variola, hence 
they were described by Bazin under the term Varioliform Acne. 
This title, however, is by most writers employed to designate a totally 
different affection, to which a chapter is devoted in this work. 

Hebra, Virchow, and JSTicolaysen have reported mollusca as large 
as an orange or a small cocoanut. Microscopical examination of these 
gigantic lesions demonstrated their identity with the smaller tumors. 
Similar bodies of less size have been found interspersed among epithe- 
liomata. 

Etiology. — In England where the disease was first recognized, it 
is more frequent than on the continent of Europe. The contagious- 
ness of molluscum is experimentally established, though the lesions 
are feeble in propagation by contact. Eetzius, Vidal, Peterson, and 
Wigglesworth succeeded in producing the disease by inoculation of 
the contents of molluscous tumors. The period of incubation after 
inoculation is from two to three months. The proofs of contagion 
apart from experimental inoculation rest chiefly upon the circum- 
stance of lesions being simultaneously or successively observed on the 
breast of a mother and the face of her nursling, and upon the suc- 
cessive development of mollusca in several members of one family. 
Ehrmann 1 believes that the disease may be conveyed from one person 
to another by the pediculus pubis. An interesting relation would 
seem to subsist between mollusca and verrucse, or ordinary warts, 
which are supposed to be feebly contagious. 

Stelwagon 2 has accumulated and classified reports of cases and of 
inoculations which seem to leave little doubt as to the parasitic nature 
of the disease, though no definite organism has yet been demonstrated 
in, or cultivated from, the growths. Eczema, sweating (Turkish 
baths), pruritus, and maceration of the skin predispose to the occur- 
rence of mollusca ; but there are insufficient grounds for assuming that 
in adults they are associated with venereal disease. They are seen 
not rarely in large numbers upon the scrotum of youths who have 
never exercised the sexiial function. 

Pathology. — Sections through the centre of a lesion of molluscum 
epitheliale show that it is formed by a number of diverging flask- 
shaped lobules, the small end of each lobule opening into a common 
central cavity. The lobules are separated from each other by a thin 



1 Ehrmann, Zweiter Internat. Dermat. Congress, Wein, 1892, p. 284. 

2 J. C. D., 1895, xiii., p. 50. 



37 



578 NEW-GEOWTHS. 

fibrous partition, which may occasionally be demonstrated to be the 
remains of a papilla. The entire mass or group of lobules is sur- 
rounded, except at the surface-opening, by a fibrous capsule, thus giv- 
ing the entire structure an appearance very similar to that of a seba- 
ceous gland. The belief, formerly held, that the process originated 
in the sebaceous glands, is erroneous. Minute examination fails to 
find any trace of a sebaceous gland in these formations. The process 
begins as a proliferation of epithelial cells in the lower layers of the 
rete. The growth is confined to the rete, from which the flask-shaped 
processes are pushed out, causing a flattening and more or less com- 
plete disappearance of the underlying papillae. 

Each lobule is lined with a layer of palisade-cells continuous 
with the same layer in the healthy rete adjoining the growth, and is 
filled with round and cuboidal nucleated epithelium undergoing pecu- 
liar changes. The first two or three rows of cells are usually normal 
but above them the changes become gradually more marked. The 
exact nature, sequence, and signification of 
Fig. 106. these changes are in dispute, but it would 

seem to be fairly well established that the 
outer part of the cell shows early in the 
process abundant granules of keratohyalin, 
and soon undergoes a cornification forming 
a clear ring or " capsule " for the cell. 
Within, the changes have been considered 
similar to those seen in amyloid or colloid 
degeneration, but C. J. White 1 found that 

Molluscous corpuscles. . , -, -, ,. , n ... 

(After Kaposi.) in over nine hundred sections the staining 

reaction of the molluscum bodies was iden- 
tical with that of normal keratin. Authors describe a granular con- 
dition surrounding the nucleus, which is usually at one end of the 
cell, while the remainder of the cell-protoplasm shows vacuoles or 
groups of small, irregularly shaped, hyaline bodies, uniting to form 
an oval mass which gradually encroaches upon and distends the cell. 
This oval homogeneous corpuscle surrounded by a horny capsule forms 
the so-called " molluscum body." These bodies accumulate at the 
mouths of the lobules and in the small common cavity in which the 
lobules all open, and may be pressed out upon the surface of the skin 
in a yellowish or whitish semifluid or waxy mass. 

The more minute changes in the cells and the methods of recog- 
nizing them are given in detail by Unna and others. The theory 
that the disease is caused by psorosperms has been abandoned. 

Diagnosis. — Mollusca resemble the lesions of variola more than 
any other cutaneous phenomena. They are, however, readily dis- 
tinguished from the latter by their chronicity, their semifluid con- 
tents, the absence of febrile symptoms, and the career of variolous pus- 
tules. From warts they are also differentiated by their contents, 
hemispherical shape, and the dark punctum almost invariably pres- 
ent on one part or another of the lesion. 

1 Loe. cit. 




PLATE XXVI [ 





Fig. 1. Xanthoma of the Hands, Elbows, and Knees. 
Fig. 2. Xanthoma Tuberosum of Penis and Scrotum. 



XANTHOMA. 579 

Molluscum epitheliale in no way suggests molluscum fibrosum, 
with which it has been confounded only in consequence of the simi- 
larity in name. The tumors of molluscum fibrosum are solid new- 
growths, usually occurring in great numbers upon the trunk of in- 
dividuals of adult years. They may attain enormous dimensions, the 
masses reaching several pounds in weight ; and though in cases they 
degenerate by ulceration, they never enclose the curdy contents of mol- 
luscum epitheliale. 

Papillary warts are to be distinguished from mollusca, though 
without question lesions are occasionally seen of a type intermediate 
between the two forms. Warts are to be recognized by their general 
papilliform character, and by their evident relation to the papillary 
layer of the corium overlaid by a thickened stratum corneum. 

Physicians are occasionally consulted by patients who have dis- 
covered mollusca upon the genitals, and who suppose these lesions to 
be of venereal origin. An error in this respect can scarcely be com- 
mitted by the expert. Neither the solid papule of the initial lesion 
of syphilis when observed on the skin of the penis, nor the pustule 
and resulting ulcer of the chancroid, exhibit the waxy look of 
genital mollusca with their depressed puncta. In such cases the 
inguinal glands should always be examined carefully, remembering, 
however, that a forcibly squeezed and cauterized molluscum may be 
accompanied by sympathetic adenopathy. 

Treatment. — When the tumors are few in number they may be 
removed by pressing out the contents through the central orifice. In 
some instances this slight operation is facilitated and rendered less 
painful by first making a linear incision over the growth. In child- 
ren and others sensitive to the pain, the surface may be rendered 
anaesthetic by the use of ice or ethyl-chloride spray. Bleeding is ar- 
rested easily with a pledget of lint. Occasionally after removal of 
the contents the point of a crayon of silver nitrate may be introduced 
either to check hemorrhage or insure destruction of the cyst, or car- 
bolic acid may be introduced on the end of a pointed stick. 

When the lesions are numerous, they may be made to exfoliate 
and disappear by the local application of green soap. Stelwagon 
recommends in such cases the use of an ointment containing 20-40 
grains (1.3-2.6) of white precipitate or of sulphur to the ounce (30.), 
the ointment being rubbed vigorously into the affected parts once or 
twice a day. 

Prognosis. — The disease can always be terminated by removal of 
the tumors, the process to be repeated in case of recurrence. 

XANTHOMA. 

(Gr., $av66c, yellow.) 
(Xanthelasma, Vitieigoidea. Fr., Plaques jaustatkes des 

Pattpieres. ) 
This affection was described by Payer 1 under the title Plaques 
jaunatres des Paupieres; by Addison and Gull (1851) as Vitili- 
1 Traite prat, des Maladies de la Peau, Paris, 1836. 



580 NEW-GEOWTHS. 

goidea; by Erasmus Wilson as Xanthelasma; and by W. F. Smith 
(1869) as Xanthoma, the name now generally accepted by writers. 

Xanthoma is a single or multiple new-growth involving the corium 
and occurring as yellowish, well-defined, round or oval nodules, 
plaques, lines, or ribands ; or as diffuse infiltrations of the skin, com- 
posed of fibrous and fatty tissue. 

The disease is observed clinically in three varieties : Xanthoma tu- 
berosum, Generalized Xanthoma, and Xanthoma Planum. 

Symptoms. — Xanthoma Tuberosum. — The classical location of the 
disease is the eyelid (Xanthoma Palpebrarum), where the lesions are 
pin-head- to pea-sized, chrome-yellow nodules which usually become 
confluent, forming plaques. They occur most frequently on the upper 
lid at the inner canthus ; they may affect the entire upper lid or the 
lower lid or encircle the eye. They first appear on one side, but after 
a time both eyelids become involved. In rare cases they develop on 
the cheeks, the nose, the ears, and the nucha. They are rarely produc- 
tive of subjective sensation, being occasionally the seat of slight pruri- 
tus. They develop very slowly, and after attaining an average size 
rarely increase or diminish. 

Generalized Xanthoma 1 is the form in which the lesions, usually 
first manifested in the sites of election and in their simplest develop- 
ment proceed to a gradual invasion of the trunk and extremities. 
The regions of greatest pressure, outside of the lids and cheeks, are 
sites of preference, as, for example, over the elbows, knees, palms, and 
buttocks, but the ears, neck, and upper chest may be involved. In 
some rare cases where the disease appears in childhood the eruption 
may become generalized. The genital region is usually affected in 
these cases. Papular and tubercular lesions may coexist with the 
plane lesions described above, and scarcely differ from the latter save 
in a greater development. The lesions are whitish or yellowish pap- 
ules, plaques, and tubercles, circumscribed in contour, millet-seed- to 
nut-sized, at times much larger, covered with an unaltered epidermis, 
and determinable by palpation as having greater consistence than the 
flat macules. They are seen less frequently upon the lids, but occur 
upon the scalp, cheeks, palmar and plantar surfaces, the genital 
region, and about the joints of the digits. 

In rare cases the tubercles may coalesce to form sessile or pedun- 
culated, nut- to hen's-egg-sized tumors which are firmer as a rule 
than the smaller lesions (Cary 2 and Chambard 3 ). 

The conglomerate forms upon the skin constitute large plaques 
resembling tumors, compounded of lesions of xanthoma tuberosum. 
They are distinctly circumscribed, deeply imbedded in the corium, 
elevated to the extent of one-fourth of an inch above the general 
level of the integument, and irregularly furrowed or lobulated super- 
ficially. 

x For bibliography, see Kichter, Monatshefte, 1903, xxxvi., pp. 57 and 126; 
and Leven, Archiv, 1903, lxvi., p. 61. 
7 Annales, 1880, s. ii., i., p. 75. 
s Arch. de Phys. norm, et path., 1879, s. ii.. vi., p. 330. 



PLATE XXVIII 



/ 





Xanthoma Tuberosum of Hands. 











}<.%*&'&&£ 



M 






$k 



£J 



4>*u?'* 



vy 



XANTHOMA. 581 

Other cases display unusual features of this disease. In one there 
may be flattened bands exhibiting xanthomatous changes in both palms, 
stretching at right-angles to the long axis of the hand; in a second 
and somewhat rare form of the disease isolated xanthomatous papules 
may be attached somewhat regularly to the edges of the lids of both 
eyes, the upper and lower equally, while large, pin-head-sized, and 
equally isolated yellowish masses are visible below the orbits on each 
cheek. 

Other organs of the body may be affected ; nodules may appear on 
the conjunctiva and cornea of the eye, in the mouth on the palate; 
in Ehodes' case nodules developed in the trachea causing obstruction 
of such degree that tracheotomy became necessary and the patient 
wore a tracheotomy tube continuously. Nodules may also form in the 
bronchi, in the oesophagus, gastro-intestinal tract, on the peritoneum, 
pericardium, spleen, and large arteries. Some of the cases of jaun- 
dice which last for years are due to xanthoma nodules forming in the 
ductus choledochus. 

In certain cases the disease is accompanied by a generalized colora- 
tion of the skin in a yellowish shade, which has been variously inter- 
preted as a xanthomatous dyschromia and as a true icterus. The 
former is the more probable explanation of the fact, as in such cases 
the urine and viscera have been found normal. A woman present- 
ing one of the extreme phases of this icteroid xanthomatous condition 
of the skin was shown at the International Congress of Dermatology 
in London in 1896. 

Lieberthal exhibited a young patient before the Chicago Derma- 
tological Society with multiple lesions of Xanthoma where the sheath 
of the tendo Achillis was involved. 

Occasionally the tubercles exhibit a fine vascularization; and 
when there is a coincident jaundice the skin between isolated lesions 
is also tinted with the color of the xanthoma nodules. The jaundice, 
so-called, is rather common in the multiplex forms; and even when 
not readily recognized, the skin at first sight of normal tint, is seen to 
be somewhat deeply colored in a shade of reddish yellow. As a rule, 
there are scarcely distinguishable subjective sensations, patients com- 
monly applying for relief of the resulting facial disfigurement. Oc- 
casionally burning and pricking, and rarely even painful sensations 
are produced. 

The course of most cases is toward a maximum of development, 
after which the process ceases. In a few instances, usually not palpe- 
bral, complete involution has occurred spontaneously. The varia- 
tions noted in the color of the plane and elevated forms of Xanthoma 
are from a light-yellow to a deep-brownish and even blackish hue. 
Cases occurring in children and infants seem to exhibit nearly the 
same features as those seen in adults. 

Xanthoma Solitarium. — In rare instances a single lesion of xan- 
thoma may be recognized over the body-surface (eyelids, chest, thigh, 
leg). In these cases the lesion usually attains the size of a large 



582 NEW-GEOWTHS. 

coin and is well elevated and denned, involving the entire thickness 
of the skin. 

Xanthoma Planum. — This is a rare form of the disease. The 
eruption consists of pin-head-sized and larger lesions which are cha- 
mois to orange color, located especially on the face, most frequently on 
the forehead, and whose chief distinguishing feature is that they are 
not elevated, but imbedded in the skin. 

Xanthoma Elasticum (Pseudo-xantlioma Elasticum) has been 
recognized by Balzer, 1 Besnier, 2 Doyen, and Bodin. 3 In this con- 
dition large coils of elastic tissue surrounded the follicles, the fibres 
being swollen and degenerated. The lesions were pin-head- to pea- 
sized, papular, yellowish patches occurring over the flexor folds, 
about the umbilicus, the clavicles, and the extremities, the eyelids 
being unaffected. Neither xanthoma- nor fat-cells were recognized. 

Etiology.- — The causes of the disease are obscure. In a few cases 
the lesions are observed first in early childhood, though they are en- 
countered chiefly in middle and later life after the fortieth year. 
Women are affected rather more often than men. 

The belief is growing that xanthoma is due to embryonic and local 
causes. Many instances are on record in which several members of 
a family were affected. Torok and T. C. Fox have each reported 
families in which members of three generations presented the disease. 
The mother, of the patient exhibiting multiple lesions upon the elbows 
and knees, whose case was selected for illustration of these pages, 
presented plane lesions of xanthoma near the inner canthi of the eyes. 
The studies of Torok 4 in this direction are instructive. The associa- 
tion of xanthoma with disease of the liver, rheumatism, gout, ovarian 
disease, migraine, syphilis, carcinoma, hydatids, and other disorders 
cannot be denied for certain cases, but in the majority no such asso- 
ciation can be recognized. Multiple plane lesions of the lid in a 
middle-aged woman have succeeded a dermatitis of that region, in- 
duced by accidental contact with a corrosive solution of mercury. 

Pathology. — The anatomy of xanthoma has been investigated spe- 
cially by Chambard, Balzer, Touton, 5 Torok, and others. The proc- 
ess is a connective-tissue new-growth, containing cells infiltrated with 
fat-granules. Aside from the new-formed connective tissue and en- 
dothelial cells there are seen between the interlacing fibres the charac- 
teristic " xanthoma-bodies." These are cells varying greatly in size, 
having a distinct membrane, granular or fibrillated protoplasm, and 
large round or oval vesicular nuclei, which vary in number from one 
to a dozen or more. 

These " xanthoma-cells " are grouped especially about and along 
the vessels, and form globular masses in the deeper parts of the cor- 
ium, though they may extend almost to the rete. They are more or 

1 Arch, de Phys., 1884, s. iii., p. 65. 

2 Trans, of Kaposi, vol. ii., p. 336. 

3 Annates, 1906, s. i\\, vii., p. 1073. 
*Ibid., 1893, s. iii., iv., pp. 1109 and 1261. 

5 Vierteljahr., 1885, xii., p. 3, with reference to previous reports. 



XANTHOMA. 583 

less infiltrated, with fat-granules, and correspond closely in structure 
to the developing fat-cells of normal connective tissue, but, as Torok 
has shown, they never go on to the formation of a fully developed cell 
containing one large drop of fat, and TJnna finds they do not respond 
to staining and other tests as do the fat-containing cells found in other 
tissues. There is seen also in the growth a transitional series of 
bodies between the connective-tissue corpuscles and the characteristic 
" xanthoma-cells." 

The epidermis is usually unchanged, though it, together with the 
papillary layer, may be slightly thinned, and there is frequently a 
deposit of a yellowish-brown pigment in the deeper layers of the 
rete. The growth is almost wholly confined to the deeper parts of 
the corium, though occasionally portions extend to the subcutaneous 
tissue and may surround the coil-glands and hair-follicles. The seba- 
ceous glands may be few, but are unchanged and are not, as was for- 
merly supposed, concerned in the process. There is often a deposit 
of pigment in the corium, both free and in the cells, but the charac- 
teristic color of xanthoma is undoubtedly due to the fat-granules. 

The icterus and hypertrophy of the liver which sometimes compli- 
cate xanthoma are probably secondary and caused by the presence of 
the growth in the liver or in the biliary passages. 

Pollitzer 1 states that eyelid xanthoma is due to a slow fatty de- 
generation of the fibres of the orbicularis muscle analogous to the 
more rapid degeneration of muscles which sometimes follows acute 
infectious diseases. He finds the xanthoma-bodies to be fragments 
of degenerated muscle-fibres, and believes that this form of the disease 
has no connection whatever with the generalized forms. 

Chambard, Morris, Crocker, and a few others believe the primary- 
process is an inflammation which is followed by a fatty degeneration 
of the cells. 2 Balzer's conclusions as to the parasitic nature of the 
disease have not been verified by more recent investigators. 

Diagnosis. — Milia occasionally occur in groups in the form of 
oval plaques upon the lids, but are distinguishable from xanthoma by 
the possibility of expressing their contents. 

The diagnosis from all other lesions is readily made when con- 
sideration is had of the peculiar yellowish or saffron-like hue of 
xanthoma, and the common situation, form, and general character- 
istics of its plane or nodular lesions. 

Pollitzer has reported a case of multiple dermoid cysts in which 
were present the clinical appearances of xanthoma. A similar case 
has been under our observation. Another is reported by Pringle. 3 

When xanthoma is represented by a single lesion upon the skin, 
the diagnosis may be attended with some difficulty. The distinctive 
differences between xanthoma and xanthoma diabeticorum are de- 
tailed in connection with the description of the disease last named. 

i J. C. D., 1897, xv., p. 367. 

2 A discussion of this question and a resume of literature are found in B. J. 
D., 1892, iv., p. 237 et seq. 

3 B. J. D., 1903, xv., p. 292. 



584 NEW-GBOWTES. 

Treatment. — Erasion and excision are the usual methods of re- 
moving xanthoma. Care should be taken in such operations to avoid 
a consequent ectropion when the operation is performed upon the 
skin of the eyelids. The Paquelin knife is objectionable on account 
of the radiation of heat to the globe of the eye. With the tumor 
slipped through an aperture in a thin sheet of asbestos paper, such as 
now is found in the market, this danger may be obviated. Morrow 
employs 25 per cent, salicylic acid plaster. Roberts makes a salicy- 
lated collodion paint — 2 parts of salicylic acid, 1 each of chrysarobin 
and castor-oil, and 4 of flexile collodion. 

The modern method, however, of treatment by electrolysis is pref- 
erable to others. The technique is the same as that employed for 
hypertrichosis and for the removal of soft moles. Caustics also 
have been employed successfully. Besnier employs phosphorus in- 
ternally, followed by turpentine, by which the course of the disease 
is said to have been relieved. Wilson, with the same end in view, 
employed nitro-muriatic acid, bitters, and blue pill. McGuire re- 
ports the removal of xanthoma by applications of monochloracetic 
acid. 

Prognosis. — The lesions, when not removed, are liable to persist 
through life. Spontaneous involution is said to occur very rarely. 
Some cases of xanthoma tuberosum, with xanthochromia and involve- 
ment of the inner coats of the larger vessels, prove serious. 

XANTHOMA DIABETICORUM.! 

(Glycosuric Xanthoma.) 

Xanthoma diabeticorum is a rare eruptive disease, occurring in 
the subjects of glycosuria, characterized by the development on the 
skin of multiple non-inflammatory, whitish, globoid papules, with a 
reddish base, resembling pustules and productive of mild subjective 
sensations. This disorder has been well illustrated by three excellent 
portraits showing the features of the malady in a case reported by 
Robinson. 2 Instances of the disease have been recorded also since 
the cases of Addison and Gull (1851) by Hillairet, Morris (who was 
the first to claim for it an independent position in the list of cutan- 
eous affections), ourselves, 3 and many others. 4 It is a disorder affect- 
ing more often glycosuric than diabetic patients, and as it is not 
demonstrably a xanthomatous affection the name by which it is 
recognized most commonly is doubly unfortunate. 

Symptoms. — The lesions are usually multiple and exceedingly 
numerous, discrete, or confluent, and not rarely grouped, pinhead- 
to pea-sized, firm, well-defined, conical, or acuminate papules. At 
the apex may be recognized a yellowish centre with reddish areola, 

1 For bibliography, see Leven, Archiv, 1903, lxvi., p. 61. 
2 Internat. Atlas. 1890, iv. 

8 Paintings in oil showing the lesions in two patients were exhibited to the 
Amer. Derm. Assoc, in New York, 1898. 

4 Pusey and Johnstone, J. C. D., 1908, xxvi., p. 552, six figures. 



PLATE XXX 




Xanthoma Diabeticorum 



XANTHOMA DIABETICORUM. 585 

which may be made to disappear temporarily under pressure. The 
appearance when viewed at some distance is suggestive of a pustule. 
Subjective sensations of itching, pricking, etc., may be produced. The 
lesions are visible over the buttocks, loins, elbows, knees, and extensor 
faces of the limbs in general, the scalp, face (brows, lips, nose), 
about the angles and over the mucous surface of the mouth, and the 
palms and soles. But one case has been reported as occurring on 
the eyelids. 

The eruptive lesions are likely to be of sudden occurrence and 
abundant at the outset. They may be firm but are generally soft 
and compressible to the touch. Occasionally they occur as punc- 
tate, linear, riband-shaped, or flattened lesions. In a large number 
of patients with trunk-lesions the abdomen is fat-distended. After 
remaining upon the surface for a few months or years they may 
wholly disappear without leaving a trace of their existence, or the 
eruptive elements may in part only disappear. Under appropriate 
treatment they may disappear with surprising rapidity. 

Etiology. — In seventeen of twenty-one cases reported, glycosuria 
has been recognized, and Johnston calls attention to the fact that in 
nearly every case the patient has been described as stout, florid, or 
obese. The majority of the patients have been male subjects and usu- 
ally in a condition of fair nutrition ; often they have been consumers 
of beer in large quantities. In yet other cases, especially in young 
subjects, there is malnutrition, and even cachexia. The patient un- 
der our observation, whose genitalia are represented in the accom- 
panying plate, suffered from diabetes insipidus, passing over a gallon 
of water daily without a trace of sugar. He suffered from chills and 
was undersized. In other cases albuminuria, nephritis, and jaundice 
have been present. 

Pathology. — Histologically the disease does not differ essentially 
from the ordinary form of xanthoma, except that inflammatory 
changes are more marked, there is less connective-tissue formation, 
and there are fewer of the xanthoma-cells than in the common variety. 
The lesions, moreover, are found usually near the coil-glands and 
follicles. Torok, Johnston, and others believe the disease to be an 
exudative dermatitis, terminating in a granulo-fatty degeneration 
which is quite distinct from the heterotopic, arrested development of 
fat seen in ordinary xanthoma. A number of the cases which have 
been reported are simply cases of xanthoma in diabetic patients. 

Diagnosis. — The difference between xanthoma and xanthoma dia- 
beticorum is based upon the following points : In xanthoma of glyco- 
suria the sudden evolution and involution of the cutaneous lesions, 
the occasional firmness and solidity of the latter as distinguished from 
the softness of the ordinary forms, and the appearance of inflamma- 
tion in the glycosuric as distinguished from the hypertrophic changes 
in the other variety. In xanthoma diabeticorum the yellowish apex 
is not at first apparent (though it may be wholly wanting), nor in 
all the lesions, and when it exists is due to epidermal changes, and 



586 NEW-GEOWTHS. 

not to those occurring in the corium, as in xanthoma. Other charac- 
teristic features of the xanthoma of diabetic subjects are the frequent 
absence of stria? and patches, of jaundice, and of eyelid-lesions, the 
presence of mild subjective sensations, the grouping of the lesions 
about the hair-follicles (well marked in Robinson's case), and the ab- 
sence of diabetes mellitus in most of the palpebral cases on record. 
This side of the question is presented by Johnston in reporting a 
case and in giving a summary of the twenty others. 1 

On the other hand, it is urged by Besnier and Doyon that the gly- 
cosuria is simply an irritating cause which explains the differing 
symptoms of xanthoma in the two classes of patients. Surveying the 
literature of xanthoma, they find patients without diabetic symptoms 
suffering from atrocious pruritus and most of the special features 
claimed as peculiar to diabetic xanthoma of glycosuria. A woman, 
however, in middle life, recognized as the subject of diabetes mellitus 
(not insipidus), examined with special care, exhibited merely the 
common form of symmetrical and plane eyelid-lesions. It is difficult 
to determine what are the relations, if any, between these two forms 
of xanthoma. 

Treatment. — The treatment of the disease, medicinal and dietetic, 
is largely that of glycosuria. Robinson's patient recovered after the 
use of small doses of Fowler's solution. Local treatment may be 
employed as indicated in any case. 

Prognosis. — The prognosis is favorable, the majority of the pa- 
tients eventually recovering. 

PSEUDO-XANTHOMA ELASTICUM. 

There are but few cases of this affection on record. 2 Balzer re- 
ported the first case in 1884. Our knowledge of the disease has 
been enhanced by Chauffard, Darier, and Bodin. 3 The eruption 
consists of a single or of several rather large chamois-colored plaques. 
They are slightly elevated and resemble xanthoma. The individual 
lesions are pin-head-sized nodules, which are discrete on the periph- 
eral portion and confluent in the central part of the plaque. In 
some of the cases the disease developed in the advanced stages of 
pulmonary tuberculosis. (C/. p. 582.) 

COLLOID METAMORPHOSIS OF THE SKIN.* 

(Colloid Milium [Wagner], Hyaloma. Fr., Collo'idome 
miliaiee [Besnier] ; Ger., Hyalom dee Hatjt.) 

Relatively few cases of this rare disorder have been reported. 
The lesions occur chiefly on the upper two-thirds of the face, espe- 
cially on the forehead and about the orbits. In C. J. White's case 5 

1 J. C. D., 1895, xiii., p. 401 ; and ibid., 1900, xviii., p. 387. 

2 Hallopeau, Annales, 1903, s. iv., iv., p. 595. 

3 Bodin, Annales 1900, s. iv., i., p. 1073. 

4 For full bibliography, see Juliusberg, Archiv, 1902, lxi., p. 175. 

5 J. C. D., 1902, xx., p. 49 (with review of literature). 



CALCIFICATION OF TEE SKIN. 587 

the backs of the hands also were involved. They consist of pin-head- 
to millet-seed- or even split-pea-sized, sharply circumscribed, irregu- 
larly rounded, flat papules, lemon-yellow in color, having a peculiar 
glistening, translucent appearance suggestive of vesicles. They pro- 
ject but slightly from the skin, and, on puncture, give exit to a soft, 
gelatinous mass, at times accompanied by a droplet of blood. Some 
of them may be surrounded by very slight telangiectases. They 
develop slowly, often in groups, the individual papules remaining 
distinct even when two or more unite. Frequently a papule becomes 
depressed in the centre ; or becomes inflamed and covered with a crust 
which falls and leaves a shallow depression but not a true scar. 

Etiology. — The cause of the disease is not known ; it occurs alike 
in men and women, usually after the forty-fifth year of age. A 
male patient presented at our clinic was twenty-five years of age 
only. In most of the cases reported the individuals lived an outdoor 
life and were much exposed to the elements. 

The Pathology has been studied by Balzer, Besnier, RebouL 
and others. Wagner's belief that the process begins in the sebaceous 
glands is now practically discarded. Colloid degeneration is found 
to affect the connective-tissue and elastic fibres of the derma, which 
may become involved over considerable areas. The changes are espe- 
cially noticeable about the vessels and nerves and about the sebaceous 
and coil-glands. The glands themselves, and all the epithelial struc- 
tures, except the endothelia of the vessels, usually escape. In sections 
examined by us removed from a clinical patient a few rete-cells and 
a few cells of the coil-gland ducts were transformed into or infiltrated 
with colloid substance. This disease is not identical with multiple 
benign cystic epithelioma (hidradenoma), in which the epithelial 
cells play an important part. 

Diagnosis.- — The disease is apt to be confounded with xanthoma, 
hydrocystoma, adenoma sebaceum, and multiple benign cystic epithe- 
lioma (hidradenoma). From the last-named disease the diagnosis is 
often very difficult or even impossible without the aid of histological 
examination. 

Treatment. — The nodules may be removed with a sharp curette or 
by electrolysis. 

CALCIFICATION OP THE SKIN. 

This unusual condition was described by Thimm 1 occurring in 
the case of a male patient, aged twenty-three years. There was a 
hard, moderately elevated tumor of eight years' duration, one cm. in 
diameter, situated on the dorsal aspect of the proximal phalanx of the 
left little finger. The lesion was described as yellowish white in 
color, having a warty center, and composed primarily by the coales- 
cence of hemp-seed-sized whitish nodules. 

A microscopic study revealed masses of calcareous material in 

1 On Calcification of the Skin, Archiv, 1902, lxii., p. 163 ; abstr. B. J. D., 1903, 
xv., p. 223. 



588 NEW-GROWTHS. 

the situations of the pilo-sebaceous follicles and also between the fib- 
rous bundles of the corium. The fibrous elements formed in areas 
a framework for the chalky deposits. There was, in addition, the 
usual picture indicative of a chronic inflammatory process. The 
writer's conclusion was that as the result of a sebaceous gland change, 
retention cysts formed which later underwent calcarous degeneration. 

In a case reported by Remes, 1 the rim of the right ear was in- 
volved. Histologically, the entire thickness of the cutis was occupied 
by a deposition of calcareous masses in a net-like granulation tissue. 
Giant cells were present in abundance. The pathogenesis of the con- 
dition he explains by assuming a degenerative change in the tissue 
preceding the calcification, which change was induced by some form 
of chronic irritation (pressure during sleep?) acting upon a part 
having low resisting powers. 

Calcareous degeneration is described by Gilchrist 2 and Stokes in 
peculiar bodies found in the lupus-like tissue. Calcareous deposits 
have also been noted in connection with milia. 

ADENOMA OF THE SEBACEOUS GLANDS.^ 

(Adenoma Sebaceum. Fr., Adenomes sebaces [Balzer and Mene- 
trier], Aden t omes sebaces cancroidaux, Acne Cancroidale.) 

The several forms of adenoma of the sebaceous glands may be 
assigned to two categories, the benign and the malignant. 

Acquired Benign Growths are pin-head- to pea-sized, sessile, spher- 
oidal, oval, or acuminate bodies, occasionally presenting points of 
whitish appearance suggestive of milium. They are situated chiefly 
over the face (forehead, furrows beside the nose). They are always 
covered with an unchanged epithelium and in color present the hue of 
the normal skin. 

Congenital Benign Growths are represented by the verrucous and 
vascular nrevi of Pringle and Darier. They increase slowly after 
birth and attain a notable development at about the period of puberty. 
They also are found about the regions of the face named above, includ- 
ing the chin and the mouth. The lesions are pin-head- to bean-sized, 
and differ from those above described chiefly in the color they present, 
which varies from a yellowish white to a deep brownish red; often 
the surface is vascularized by the presence of minute capillaries. 
They are sometimes discrete, often confluent, and may be commingled 
with comedones, acne-pustules, pigmented patches, and the lesions 
of facial seborrhoea. In the majority of cases other defects of the 
skin, such as warts, nawi, small papillomata, and pigment-spots, are 
present, while many of the patients reported have been mentally de- 
ficient or epileptic. 

1 Archiv, 1907, lxxxviii., p. 265 (with resume of reported cases). 

2 The Presence of Peculiar Calcified bodies in Lupus-like Tissue, J. C. D., 1903, 
xxi., p. 463. 

3 For bibliography, see Darier, La Pratique Dermatologique, t. i., p. 284; 
Pezzoli, Archiv, 1900, liv., p. 192; Pick, Ibid., 1901, lviii., p. 201; Marullo, Zeit- 
schrift, 1902, ix., p. 166; Kothe, Archiv, 1904, lxviii., p. 33. 



ADENOMA OF THE SEBACEOUS GLANDS. 589 

The two forms named above are benign lobulated tumors of the 
type of sebaceous adenoma, the last-named group being distinguished 
by delicate telangiectases over the surface and a verrucous structure. 

Malignant forms of Sebaceous Adenoma occur when the skin is in 
the senile state. They begin with the symptoms of an irritable acne 
or seborrhcea, greasy crusts being displayed here and there, particu- 
larly over the surface of the face ; or with comedones of unusual type ; 
or with papulo-pustules that do not pursue the course of those seen in 
earlier years. Ulceration attacks the lesion which at first seemed 
benign, and the issue is the development of an epithelioma. Pick 1 
reports a case in which small epitheliomatous tumors formed similar 
to those seen in multiple benign cystic epithelioma (q. v.). 

Etiology. — These growths are developmental defects of the skin 
which frequently appear for the first time in adult life. Most of 
the cases reported have been in the poor and in those of defective 
mental development, but cases are seen also in the well-to-do and 
intelligent. 

Fig. 107. 




Adenoma sebaceum (Heidingsfeld). 



Pathology. — The histology of these bodies has been studied by 
Pringle, Darier, Baker, Crocker, Pollitzer, and others. There is 
hyperplasia of the sebaceous glands, which are numerous and large. 
Beyond this observers do not agree, and further study of the subject 
is necessary. Pringle described an interpapillary hypertrophy; Bal- 

2 Log. cit. 



590 NEW-GROWTHS. 

zer found small cysts in both sebaceous and sweat-glands ; Crocker 
reported an increased development of the coil-glands and hair-follicles, 
in addition to hyperplasia of the sebaceous glands. 

Diagnosis. — The history of the disease, which begins in early life 
and develops gradually ; the persistency and permanency of the indi- 
vidual lesions situated chiefly on the middle of the face and specially 
in the naso-labial folds; the frequent occurrence of telangiectases 
with the papules above described ; and the absence of suppuration 
or ulceration will usually suffice for a diagnosis. In colloid milium 
the lesions are usually few in number, are situated chiefly on the 
frontal and orbital regions, have a peculiar yellowish, translucent ap- 
pearance, and are not so much modified by telangiectases. In multi- 
ple benign cystic epithelioma the lesions occur on the forehead and 
also on the trunk. Both of the two last-named diseases, however, 
may so closely resemble adenoma sebaceum as to render the differen- 
tial diagnosis impossible without the aid of histological examination. 

Treatment. — Neither internal remedies nor external applications 
have any influence upon the lesions. The treatment is, therefore, 
surgical and calls for the employment of the knife, the curette, or scar- 
ification, depending upon the size, number, and location of the lesions. 
In several cases the latter have been removed successfully by means 
of electrolysis. 

MULTIPLE BENIGN CYSTIC EPITHELIOMA. 1 

(Trichoepithelioma Papulosum Multiplex; Hemangio-Endo- 
thelioma; Linear ISLevi.) 

Much confusion has existed respecting this disorder described from 
different points of view by different writers as shown by the titles 
given above. The following description practically covers the clinical 

1 Bibliography : Balzer and Menetrier, Archiv de Physiol., 1885, vi. Balzer 
and Grandhomme, Archiv de Physiol., 1886, vii. Birch-Hirschfeld, Allge. patholog. 
Anatomie, 1890. Blaschko, Berlin Dermatol. Soc, June 14, 1898. Brooke, B. J. 
D., 1892, iv., p. 269; Monatshefte, 1892, xv., p. 589. Christian, Dissert., Berlin, 
1903. Crocker, "Diseases of the Skin," 3d ed., p. 988, and Trans. London Clini- 
cal Soc, 1899, xxxii., p. 151. Csillag, Archiv, 1904, lxxii., p. 175; ibid., 1906, 
lxxx., p. 163. Delbanco, Munch, med. Wochensch., 1901, No. 39. Dohi, Archiv, 
1907, lxxxviii., p. 63. Dorst and Delblanco, Monatshefte, 1901, xxxiii., p. 317. 
Fellander, Archiv, 1905, lxxiv., p. 203. Fordyce, J. C. D., 1892, x., p. 467; ibid., 

1890, viii., p. 459. Fox, B. J. D., 1897, ix., p. 230 (case report). Gassman, 
Archiv, 1901, lviii., p. 177. Gottheil, J. A. M. A., 1901, xxxvii., p. 176. Guth, 
Archiv, 1900, (Festschr. Kaposi). Hartzell, B. J. D., 1904, xvi., p. 361. Hallo- 
peau, Annales, 1890, s. iii., i., p. 872. Heidingsfeld, J. C. D., 1908, xxvi., p. 18. 
Jamieson, B. J. D., 1893, v., p. 138. Jarisch, Archiv, 1894, xxviii., p. 163. 
Kleintjes, Dissert. Miinchen, 1904. Kreibich, Derm. Zeitsch., 1906, xi., p. 675. 
Krzysztalowicz, Monatshefte, 1907, xlv., p. 1. Lesser and Beneke, Virchow's 
Archiv, 1891, cxxiii. Perthes, Deutsch. Zeitsch. f. Chir., Ixv. Phillipson, B. J. D., 

1891, iii., p. 33. Pick, Archiv, 1901, lviii., pp. 201 and 215. Pollitzer, J. C. D., 
1891, ix., p. 281. Poor, Monatshefte, 1905, xl., p. 379. Pringle, B. J. D., 1890, 
ii., p. 1. ' Eeitmann, Archiv, 1907, lxxxiii., p. 177. Sagory, These de Paris, 1906. 
Thiersch, Archiv, 1904, Ixix., p. 3. Wilhelm (Vienna Derm. Soc, Feb. 8, 1905), 
Archiv, 1905, lxxvi., p. 417. Wolters, ibid., 1901, lxv., pp. 89 and 197. Werner 
and Jadassohn, ibid., 1895, xxxiii., p. 355. Werther, ibid., 1907, lxxxviii., p. 334. 
White, J. C, J. C. and G. U. Dis., 1894, xii., p. 474. 



MULTIPLE BENIGN CYSTIC EPITHELIOMA. 591 

appearances recognized by most observers excluding all cases of sy- 
ringocystoma. 

Symptoms. — The lesions occur most often in the face (about the 
root of the nose, the temples, eyelids, cheeks, forehead, and chin), 
the neck, the mammary glands, and upper extremities but may de- 
velop in any part of the body. The lesions are minute, pearly, pale, 
yellowish or pinkish tumors, sometimes yellowish red, even at times 
having a bluish shade, varying in size from a small pin's head to that 
of a pea though much larger lesions may develop. They are firmly 
imbedded in the skin; project to a variable degree above the surface; 
are round or oval, solid and painless to the touch, the larger tumors 
being tense, lucent, and freely movable over the underlying tissue, 
and develop slowly, the growth ceasing after a time. In some cases 
the lesions are translucent and suggest in their appearance vesicles ; 
others resemble milia; still others may be the seat of fine telangiec- 
tases ; in yet others there is a central depression sometimes having a 
blackish point. These central points at times represent the partial 
cicatrix of a small ulcer. Lastly there are those which resemble 
crateriform epithelioma. The lesions are discrete and not in any 
way characteristically grouped. They are not as a rule the seat of 
subjective sensations, most patients applying for relief on account of 
their appearance when developed on the face. In some instances 
they are symmetrically arranged though not grouped. 

Etiology. — The disease occurs most often at about the period of 
puberty, in women more frequently than in men. In some cases 
there is distinctly inherited tendency to the disease. 

Pathology. — The reports on the pathological findings in different 
cases differ according to the point of view of the investigator. Heid- 
ingsfeld for example, recognizing the hyperplasia of the sebaceous 
glands and, comparing this change with that occurring in lymphan- 
gioma tuberosum multiplex originating chiefly in the lymph- and 
blood-vessels, finds that these affections have a common pathogenesis 
from misplaced embryonal tissue. 

Fordyce recognized irregularly rounded, oval, elongated masses 
and tracts of epithelial cells corresponding to those in the lowermost 
layer of the epidermis and the external root-sheath of the hair-follicle. 
The epithelial masses may be distinct, or made up of intercommuni- 
cating bands and tracts, in some places resembling coil-ducts. " Cell- 
nests" are met with as in malignant epithelioma, enclosing horny, 
granular, and colloid tissue. Colloid degeneration of individual cells 
is also encountered in the cell-masses. The connective tissue about 
the cell-collections is somewhat condensed, but is not the seat of any 
inflammatory process. 

Jarisch, White, Hallopeau, Wolters, Pick, and Hartzell practi- 
cally agree with the findings described above, recognizing the infiltra- 
tion of the derma with irregular or ramifying epithelial masses clearly 
defined, often with distinctly colored cells, disposed at the periphery 
" like a palisade " with more or less central degeneration where may 
also be found a cyst. 



592 NEW-GROWTHS. 

See and others have recognized in the corium variously sized, dis- 
tended, sometimes swollen cysts in great numbers having epithelial 
walls and stuffed with colloid masses. 

Dubreuilh and Auche 1 found large numbers of connective tissue 
cells at the periphery of the tumors with plasma-cells and a few mast- 
cells. The sweat and sebaceous glands were not involved. 

Treatment. — The growths can be removed by all surgical 
measures ; by radiotherapy ; by electrolysis ; by liquid air ; or by pen- 
cils of frozen carbon dioxid. 

Prognosis. — A large majority of all cases terminate favorably. 
Many make no progress toward degeneration after years without 
treatment. In but very few cases malignant growths develop. 2 

SYRINGOCYSTOMA.3 

(Hidradenomes eruptifs [Jacquet and Darier] ; Syringo-cyst- 
adenome [T6rok] ; Epitheliome kystique benin [Jacquet] ; 
Cellulome epithelial eruptif [Quinquaud] ; Cystadenome 
epithelial bentn [Besnier] ; Lymphangioma tuberosum mul- 
tiplex [Kaposi] ; Adenoma sebaceum ; Acanthoma adenoides 
cysticum; Syringocystoma [Neumann] ; Syringoma [Fiocco]. 
Ger., Schweissdrusen Adenom mit Cystenbildung.) 

A group of rare cases, less than two score in number, the first de- 
scribed by Darier and Jacquet; others later by the observers whose 
names are given above, and yet others quite recently by C. J. White, 
of Boston, has been definitely recognized as distinct from the condi- 
tions commonly described as multiple benign cystic epithelioma. The 
clinical picture of syringocystoma is now fairly differentiated from 
others. 

Symptoms. — The patients are for the most part women in early 
life, exhibiting an odd-looking eruption in the form of distinctly out- 
lined patches over the neck, clavicles, shoulders, and chest, but espe- 
cially over the axillae, more rarely over the face, eyelids, nose, ears, 
scalp, abdomen, and extremities. In a patient examined by us the 
lesions were equally characteristic but less numerous in the groins. 
The general health of the subjects of the disease is unimpaired. 
There are few, if any, subjective sensations. 

The eruptive elements are pinhead to split-pea-sized (in Braun's 
case they attained the size of a hazel nut), roundish, rather closely 
set, smooth, globoid nodules, in some cases discrete, in others so 
closely packed as to assume the shape enforced by the juxtaposition 

1 Annales, 1903, s. iv., p. 53. 

2 Annales, 1902, iv., s., iii., 545. 

s Partial Bibliography: Darier, La Prat. Derm., 1900, i., 288; White, C. J., 
J. C. D., 1907, xxv., 49, full bibliography, four plates, six histological figures; 
Jacquet and Darier, Annales, 1887, s. ii., viii., 317, with plate; Jacquet, Congres 
Intern, de Derm. Paris, 1889; Perry, Atlas of Bare Skin Dis., 1890, Pt. 3, PI. 9; 
Neumann, Archiv, 1900, liv., 3; Brauns, Archiv, 1903, lxiv., 347; Fiocco, Giorn. 
Ital. d. Mai. Ven. e. d. Pel., 1904, 3; Besnier, Trans, of Kaposi's Treatise, ii., 367. 



PLATE XXXI 




Syringoeystoma 



XERODERMA PIGMENTOSUM. 593 

of neighboring lesions. They are softish in consistency, fawn-colored 
to yellow in some subjects, in others having a brownish almost a choco- 
late-tinted hne. They produce no sense of roughness to the touch 
when handled, and being in moist situations suggest that they are to 
a degree macerated with sweat coming from the sound adjacent skin. 
They arrange themselves usually along the natural folds of the skin. 

The course of the disease is toward persistence of the lesions after 
attaining a maximum development when not removed by treatment. 

Histopathology.- — The essential change, according to Darier and 
White, is to be recognized in the corium, the papillary and sub-papil- 
lary layers of which are practically unchanged. Between the sub- 
papillary layer and the panniculus adiposus lie clusters ("epithelial 
cylindrical tracts") of epithelial cells, variously shaped, surrounded 
by a connective tissue which seems to have undergone collagenous 
degeneration. Within the clusters a central lumen develops, with 
round, swollen, translucent, granular cells often blocked with 
" globes " of colloid material. In the case of Jacquet and Darier, 
there were ramifying prolongations in the corium showing canals, and 
cysts with amorphous contents ; while in Neumann's exceptional 
case, the rete-pegs, the vessels, sebaceous glands, and arrector muscles 
were changed. In but a few of the recorded cases has a distinct con- 
nection between the cysts and the sweat-coils been demonstrable. 
White in summing up the conclusions of similar cases believes that 
the disorder is a hyperplastic and hypertrophic change in previously 
existing efferent sweat-ducts. 

Diagnosis. — The diagnosis is to be established chiefly from multi- 
ple benign cystic epithelioma, the softish nodules of syringocystoma 
with their general hue, distribution, and lack of pearly elements, ren- 
dering the clinical recognition facile. Papular syphilodermata are, 
as a rule, accompanied by other signs of lues ; the xanthomata have a 
more yellowish tint but in many respects strongly resemble the lesions 
of syringocystoma. 

Treatment. — The treatment recommended by Darier and Brocq 
is by electro-cauterization or excision. 

XERODERMA PIGMENTOSUM.* 

(Gr., fepoc, hard; dep/ua, the skin.) 

(Angioma Pigmentosum et Atrophicum; Atrophoderma Pig- 
mentosum, Dermatosis Kaposi, Melanosis Lenticularis 
Progressiva, Lioderma Essentialis cum Melanosi et Tel- 
angiectasia. Lentigo Maligna. Fr., Epitheliomatose 

PIGMENTAIRE.) 

Xeroderma pigmentosum is a rare disease, described by different 
authors under the several titles given above, but most often designated 
by the name given as the title of this section. It was recognized 

1 Bibliography : Kaposi, Wien. med. Wchnschrft., 1885, p. 1334; Ibid., Twen- 
tieth Century Practice, vol. v., p. 727; Lukasievicsz, Archiv, 1895, xxxiii., p. 37 
38 



594 



yEW-GHOWTHS. 



first and described by Kaposi, in 1863, on the basis of two cases seen 
by the elder Hebra and himself, this number being increased by two 
in the year 1870. Since then more than one hundred cases have 
been placed on record in different countries, and about a score in 
America by Taylor, Duhring, White, Bronson, Drayton, Hutchins, 
Bowen, and others, including the author. Kecently we have studied 
the disease in three children of one family, the patients being the sub- 
ject of the illustrations of the disease in the present edition of this 
treatise. 

Symptoms. — The disease begins most often in early life, from the 
third or the fifth month to the close of the first year, though it has 
been observed first in adults and even at an advanced age. Some 



Fig. 10S. 




Xeroderma pigmentoa 



doubt however, exists as to the occurrence of classical features of the 
malady in the cases developing at these later periods. 

The special stigmata of xeroderma pigmentosum are its symptom- 
groups, any one of which may be encountered not rarely in other 

{resume of seventy-three eases, and bibliography) ; Kreibich, Archiv, 1901, Ivii., 
p. 123; Monthus, Annales, 1902, s. iv., iii., p. 673; Lowenbach, Mracek's Handbuch, 
Bd. iii., p. 240 (with full bibliography) ; Crocker, Diseases of the Skin, 3d ed., p. 
681 ; Herkheimer u. Hildebrand, Munch, med. Wchnschrft., 1900, xlviii., p. 1099 
(full abstr. in B. J. D., 1901, xiii., p. 66) ; Nicolas and Favre, Annales, 1906, s. iv., 
vii., pp. 536-549, Michael Terterjanz, Inaug.-Dissert. Berlin, 1902; Klein, Inaug.- 
Dissert., Strassburg, 1906; Terebinski, Eusski Wratsch., 1906, No. 48; Vignolo- 
Lutati, Monatsh., 1907, xlv., pp. 21-31, 72-91; Josef Cuszman, Centralb., 1907, 
x., pp. 258-267; Low, Zeitsch., 1906, xiii., pp. 488-498; Forster, Deutsche, med. 
Zeit., 1904, No. 74, 77; Adrian, Centralbl., 1904, vii., 130; Askura, Japan, Zeits. 
f. Derm. u. Med., 1906, p. 1 (2 cases). 



XERODERMA PIGMENTOSUM. 595 

diseases, but the complexus of which is scarcely to be seen in any other 
affection, and in particular at an early period of life. The term, 
senilitas prsecox, has been applied aptly to the condition of the young 
subjects of the disorder. An analysis of the phenomena presented 
in a well-marked case shows that pigmentation, atrophy, telangiec- 
tasis, and new-growth development coexist. 

Fig. 109. 




Xeroderma pigmentosum. 

At the outset, the mothers of children and some observant phy- 
sicians have seen an erythematous redness, diffuse or in circumscribed 
maculae, over the regions later characteristically involved. More 
often the first signs of the disease are visible in a well-marked freck- 
ling of the skin, the lentigines scarcely if at all differing from those 
resulting from exposure to the light in persons subject to that form 
of pigmentation. This freckling, or pigmentation, in almost every 
instance involves the exposed surfaces of the body, more particularly 
the face, neck, upper chest as far as the third rib, the hands, the 
forearms from the upper third as far as the finger-tips, including to 
a minor extent the flexor aspect of the arms and the palms. In our 
little patients there was a distinct triangulation of pigmentation, the 
apex of the triangle below extending down the back nearly to the sac- 
rum. Occasionally the thighs, the legs, the scalp, the sub-ungual 



596 NEW-GROWTHS. 

spaces, the dorsa of the foot, the trunk, and buttocks may likewise be 
involved. 

The patients are commonly of blond type, with reddish or light- 
tinted hair and blue or lightly pigmented irides ; in short, of the class 
chiefly disposed to freckling. The pigmentations in these cases dif- 
fer as to hue with the age of the patient and the severity of the disease, 
the color ranging from a light fawn-yellow to a deep chocolate-brown. 
The lentigines may be isolated, as is the rule ; or be fused in areas of 
one or several centimetres diameter. 

Interspersed among the lentigines are equally characteristic whit- 
ish atrophic spots, usually less pronounced than the lesions described 
above, which may be isolated or coalesce into cicatriform patches. 
When sparse, they are somewhat lucent, slightly wrinkled, smooth, 
or covered with micaceous scales. They may precede the occurrence 
of the pigmentations or follow the latter, or even follow the develop- 
ment of the telangiectases described below. Crocker ascribes to these 
atrophic areas the production of ectropion, which is a common feature 
of many cases ; but in our experience the ectropion results from epi- 
theliomatous infiltration of the lower lids, precisely as in epithelioma- 
tosis of adults. 

The telangiectases, which are equally common and characteristic 
of the disease, may be punctate or stellate ; they are usually fine and 
conspicuous by contrast with the pigmented skin in which they de- 
velop though they may result in minute pinhead-sized tumors of the 
skin not rarely observed on the trunk of men and women of advanced 
years. They may be few or numerous, and are less conspicuous as a 
rule on the surfaces covered with the clothing than elsewhere in the 
regions exposed to the light. 

The new-growths visible in the victims of the disease vary greatly 
in type, but we believe that all are epitheliomatous in character, the 
different clinical features described by observers not suggesting a 
wider variation than can be determined in any study of the clinical 
appearances of epithelioma in the skin of persons of advanced years, 
including the lesions seen in that class of subjects described as verru- 
cous, papillary, discoid, fungating, deep-seated, rodent ulcer, etc. 

Thus, for example, in xeroderma pigmentosum there may be pea- 
sized or larger, flattened or pointed warty growths, irregularly dis- 
seminated among the lentigines, or conspicuously developing at iso- 
lated points, such as the back of the hand or in front of one ear. In 
other cases there is a distinct circumscribed epitheliomatous infiltra- 
tion not productive of a tumor, cases of the sort referred to above, 
where ectropion ensues precisely as in the case of aged persons with 
carcinoma of the tissues in or near the lower lid. 

The other symptoms of xeroderma pigmentosum are related more 
or less closely to the chief lesions described above. There may be 
open or crusted ulcerations resulting from circumscribed epithelioma- 
tosis. In one of our patients, a boy four years of age, a lesion devel- 
oped in the tragus of one ear which might serve as a classical illustra- 



XERODERMA PIGMENTOSUM. 597 

tion of the "rodent ulcer" of English writers. Healing of such 
ulcers may result further in deforming cicatrization. Papillomatous 
tumors, developing from cicatrices or directly from freckle-like lesions 
may assume eventually epitheliomatous characters. Keratitis is ex- 
ceedingly common, and this in the early periods of the disorder ac- 
companied by photophobia, profuse semipurulent lachrymation, and, 
according to Crocker, producing extension of the disease by the flow 
of the secretion over the cheeks. Corneal opacities, sufficient to ob- 
struct vision even in the very young, occur to a grave extent. A pro- 
fuse catarrhal discharge from the nose, with extension of the disease 
to the Schneiderian membrane and also to the inner faces of the lips 
and buccal cavity, may result. The scalp may be free, or the seat of 
pityriasic scaling or of lentigines. Sensation and perspiration may 
be impaired to a varying extent. Often, as the disease progresses, a 
characteristic thinning of the affected integument occurs, producing 
the so-called parchment-skin. 

In very young subjects the partially blind patient has an apa- 
thetic expression and listless demeanor which are highly characteris- 
tic. The course of the disease is variable ; some of the children 
dying of marasmus in the course of a few months ; others surviving 
to adult years. The disease may seem for months at a time to be 
arrested, after which it may be reawakened to activity. 

Audry reports, 1 an exceedingly rare case in which xeroderma pig- 
mentosum developed without pigmentation in a male patient, 24 years 
of age, an epithelioma of the lower lip developing between the third 
and fourth year of life. The author, as a consequence, places in the 
first rank of symptoms of this disease the redness, the vasculariza- 
tion, the atrophy, and the pseudo-ichthyosis of the skin; and calls 
attention to the fact that all other symptoms may be lacking, the 
epithelimatous being only a superadded change. Audry does not hesi- 
tate to declare absolutely that on the basis of pathological findings 
there is no connection, in fact, an absolute distinction, between, the 
cases of xeroderma pigmentosum in childhood and those reported as 
occurring late in life. 

A number of cases of xeroderma pigmentosum have been reported 
as first occurring in adult years and even at an advanced age. There 
is however, some doubt as to whether those first suffering at this age 
should be included in the class with the childhood cases. Thus, for 
example, Beurmann and Gkragerot, 2 report details of the case of a 
male patient (67 years of age) affected with a gastric epithelioma, 
whose symptoms closely simulated those of xeroderma pigmentosum, 
viz., minute multiple angiomata distributed over the exposed parts 
of the body (head, etc.), with whitish atrophic points having a pig- 
mented areola, accompanied by puncta of hyperpigmentation about 
the head and trunk. On the other hand Sequeira 3 reports an un- 

1 Annales, 1907, s. iv., viii., pp. 199-204. 

2 Annates, 1906, s. iv., vii., p. 391. 

3 B. J. J)., 1906, xviii., p. 203. 



598 NEW-GEOWTHS. 

doubted case in a man 26 years of age who had suffered since early- 
childhood. 

Etiology.- — The cause of the disease is unknown, but the records 
indicate clearly that in many cases there is a strongly marked family 
predisposition to the disease, not merely because of the frequency 
with which several members of one family have been affected, but 
also because of the consanguinity of a few families with children sim- 
ilarly attacked. About twenty-four per cent, of all the recorded cases 
occur in the families of Israelites. The disease is represented equally 
in the two sexes; many brothers and sisters of affected children are 
free from the disease. Beginning for the most part in the first year 
of life, a few senile instances have been reported in which the earliest 
symptoms were declared at an advanced age. The influence of light 
upon the development of the disease in susceptible subjects has been 
pronounced effective by several authors, and while it is true that, as in 
one of our cases, the lower limbs and trunk, as well as the dorsa of the 
feet, were involved, the preponderance of testimony decidedly points, 
in the victims of the disorder, to an extreme susceptibility of the skin 
to the action of sunlight, an agency by no means set aside when the 
light clothing of many young subjects envelops the skin. 

Pathology. — The disease seems to be a cutaneous metamorphosis, 
the primary factor in which is less a primary neurosis, as has been 
taught, than a special susceptibility to the action of the light-rays, 
a fact declared in the well-nigh invariable ocular symptoms developed 
in the subjects of the disease. Whether the morbid process is pri- 
marily degenerative, or is rather, as the facts tend to show, at the 
outset reactive in the line of erythematous redness followed by de- 
generative changes; remains to be seen. In Adnou's case (child 23 
months old) there was diminished hemoglobin and increased erythro- 
cytes. 

Bandler, 1 in the histological examination of a patient, 24 years 
old, under his charge, found that the morbid process was limited to 
the epidermis and the upper corium and the blood vessels of the con- 
nective tissue while the deeper cutis and hypoderm remained intact. 
The author found evidences of typical epithelioma and in one place 
alveolar nsevus carcinoma. 

The two tumors examined presented a difference in characteristics, 
one that of a typical epithelioma with little tendency to enlargement 
having limitations ; the second that of carcinoma with irregular prolif- 
eration, atypical in type with degenerative tendencies. 

The tumors and warty growths developed in the course of the dis- 
ease have been examined repeatedly in section with findings variously 
interpreted. Okamura recognized an oligocythemia and leukocytosis 
in Kaposi's cases; Crocker, Vidal, Taylor, and Kreibich describe 
practically the same condition, though variously interpreted by them 
— viz., epitheliomatous nests, aggregations of long branching cylin- 
ders enclosing epithelial cells (" tubular" type, of cancer), and, ac- 

1 Archiv, 1905, Ixxvi., pp. 9-30. 



XEBODEBMA PIGMENTOSUM. 599 

cording to Pollitzer, '"mixed elements," sarcomatous, myxomatous, 
sarco-carcinomatous, granulomatous, etc. Some of the tumors are 
typical instances of tubular epithelioma. There is general agree- 
ment as to the obvious fact that the morbid process in all the new- 
growths is practically an epitheliomatosis, a fact strongly empha- 
sized when Quinquaud demonstrated the nature of his classical cases 
before the International Congress in Paris, in the year 1889. 

Diagnosis. — Xeroderma pigmentosum is so pronounced in its feat- 
ures that it is seldom an error is made in its recognition. The early 
date of its onset for the most of cases, the combination of pigmenta- 
tion, telangiectasis, atrophic patches, and the development in the 
child's skin of warty growths, are all significant. The pigmented, 
atrophic, and occasionally vascularized tissue of scleroderma might 
possibly be mistaken for the disease under consideration but the 
leather-like condition of the integument in scleroderma, its pigmenta- 
tion in irregular areas (rather than in macular lesions suggesting 
freckles), its limitation to definite areas other than those exposed to 
the light, and in the circumscribed types its frequent development in 
the regions supplied by cutaneous nerves — all these are significant. 

Treatment. — Up to the present time, treatment of the disease has 
proved unavailing. Internally, cod-liver oil, tonics, the salts of 
iodine, and arsenic have all been employed. Crocker lays stress upon 
active and prompt surgical treatment of the ocular lesions and epithe- 
liomatous growths after their development either as tumors or ulcers. 

Little stress has been laid upon the hygienic management of these 
cases, which we have found of high value. Our patients improved 
greatly under hospital care. We employed the x-ray with excellent 
results in the treatment of several of the epitheliomatous ulcers, 
which speedily went on to repair under the influence of the ray. 
Sichel, 1 and Balzer and Merle 2 had a similar experience. At the 
same time, seeing that in cases radiotherapy has produced both pig- 
mentation, telangiectasis, and atrophy, it would appear on a priori 
grounds an inexpedient method for adoption in these conditions. 

Hahn and Weick, 3 experimented upon two cases with' different 
forms of light treatment including Finsen's rays, the Uviol, and 
the quartz lamp. The results did not seem to be conclusive. 

Prognosis. — The outlook for the majority of cases is exceedingly 
grave, most patients eventually perishing from the immediate or re- 
mote results of cancerous changes. Two of Crocker's patients lived 
for nineteen years; another (supposed "senile" case) suffered for 
forty years. Precocity in wart- and tumor-development is said not to 
indicate special gravity for the future. 

1 Guy's Hospital Gaz. Mar., xxiv., p. 114. 

2 Annales, 1906, s. iv., vii., p. 1054. 

3 Archiv, 1907, lxxxvii., pp. 371-398. 



600 XEW-GBOWTHS. 

RHINOSCLEROMA.i 

(Gr., l>ir, or f>lv, the nose, and gk////hic, hard.) 

Symptoms. — A knowledge of this rare disease, first described by 
Hebra and Kaposi in 1870, has been obtained from a study of some 
one hundred cases observed by these and other authors. The follow- 
ing is a concise description of the malady as thus presented. 

The disease commonly begins in the septum or a single ala of the 
nose, without inflammatory symptoms. The involved parts slowly 
enlarge, and become finally as dense as ivory. The individual lesions 
are flat patches, or elevated and circumscribed nodules, papules, 
and tubercles, painful upon pressure, movable to a certain extent over 
underlying tissues, and covered either by a normal integument, or by 
a light- or dark-red, shining, vascular epidermis. Neither hairs nor 
glands are discernible over the lesions. As the disease progresses the 
alas become enlarged, flattened, and so indurated that they cannot be 
pressed together, while respiration may be impeded by stenosis of the 
nares. The process may extend to the neighboring parts, involving 
thus the upper and lower lips, gums, velum, epiglottis, larynx, trachea 
and jaws, the teeth meanwhile falling from their sockets and the soft 
palate becoming in some cases perforated. Involution of the process 
has not been observed, and the lesions do not degenerate by ulceration. 
Max Zeissl, 2 however, reports a case in which there was ulcerative 
destruction of the entire left nostril, as well as of the tip and right 
ala of the nose. Occasionally superficial excoriations have occurred, 
but very rarely a diminution in the consistency of the mass. The 
disease pursues a chronic course, requiring years for its development ; 
and though the affected parts are painful on pressure they are other- 
wise not the seat of subjective sensation. 

Etiology and Pathology. — The disease is observed between the 
fifteenth and fortieth years in persons of all social conditions and in 
individuals of both sexes, free from syphilitic, tubercular, and other 
cachexias. 

Kaposi originally observed, as anatomical lesions of the disease, a 
dense infiltration of the corium and its papillary layers with small 
closely packed elements, which he recognized as a true new-formation. 
He considered this as analogous to small-cell sarcoma, inasmuch as 
Mikulicz, Geber, and Billroth had seen some of the elements of the 
neoplasm undergoing the osseous transformation common in sar- 
comatous tumors. 

In 1882 A. von Frisch, after examining tissue removed from 
lesions of rhinoscleroma in twelve patients, found in the cells and 
between them in the interpapillary fissures of the connective tissue 
bacteria, distinctly rod-shaped, one and one-half times longer than 
broad. These bacilli were successfully cultivated, and though exper- 

1 For bibliography see Marschalko, Archiv, 1900, liii., p. 163, and liv., p. 235 
(a histological and bacteriological study of two cases with full review of sub- 
ject) ; and Castex, La Pratique Dermatologique, t. iv., p. 187. 

2 Wien. med. Wchnschrift., 1880, p. 621. 



BHINOSCLEEOMA. 601 

imental inoculations with culture-fluids thus obtained were negative 
in results, the organism of Frisch has been considered to be the cause 
of rhinoscleroma. 

The bacilli are found encapsulated in a colloid-like substance 
and in series of twos and fours. They occur chiefly in certain large 
bladder-like cells which are characteristic of the disease, and which 
are known as Mikulicz cells. They are found also in plasma cells, 
in the interepithelial spaces, and in the lymph channels. Metastases 
have been recognized in neighboring glands. Two forms of cells 
have been distinguished by Mibelli, one a dropsical and another a 
colloid. Both have been regarded as products of degeneration from 
the toxines of the organism, but it is possible that the former, which 
corresponds to the Mikulicz cell, owes its peculiar character to the 
presence of zooglea, a mucoid substance produced by the bacilli which 
have invaded the cell. Pawlowsky, of Kieff, in 1890, demonstrated 
that the bacilli of the disease are pathogenic for the lower animals. 

Dreschfield 1 found in sections of tissue obtained from a patient of 
Payne's numerous bacilli less slender and smaller than those occurring 
in tuberculosis and with slightly thickened extremities. These were 
unlike those exhibited at the Berlin Congress by Paltauf, who con- 
siders them closely related to Friedlander's pneumococcus. 

While Barduzzi, Pellizari, Cornil, Alvarez, Lustgarten, and others 
have contributed to the evidence in favor of the parasitic nature of 
the disease, Besnier and Doyon, however, pointing to the limitation 
of the disease to Austria, reject a parasitic origin. Against the spe- 
cificity of the bacillus of Frisch is argued the difficulty of distinguish- 
ing that organism from the pneumococcus and other forms which 
might conceivably penetrate the tissues from the nasal cavity ; the uni- 
form failure to produce the disease by inoculation in man ; the ab- 
sence of contact-infections though the nasal discharge of the victim 
be loaded with bacilli ; and the fact that it is endemic in a relatively 
limited area. Bogers 2 calls attention to the fact that no other mem- 
ber of the group to which the bacillus of Frisch is shown to belong 
by cultural characters is known to produce lesions of productive type ; 
they are all invariably pyogenic ; therefore if it is the cause of rhino- 
scleroma, it is in every way an exception to its group. 

Diagnosis. — The disease can hardly be mistaken for another in 
consequence of its situation, the disfigurement it occasions, the ivory- 
like elasticity and induration of the affected parts, and the rarity of 
ulcerative degeneration. As distinguished from syphilis, it is known 
to be unaffected by specific medication. Since rhinoscleroma, how- 
ever, has been by some writers assumed to be a form of syphilis, it is 
needful to distinguish clearly between the two. But as in the former 
affection there is rarely softening of the ivory-like induration, much 
less ulceration, which is common in syphilitic gummata, the distinc- 
tion is tolerably clear. From the variety of acne rosacea of the nose 

^rit. Med. Jour., 1885, ii., p. 837. 
2 Jour. Infect. Dis., 1907, iv., p. 51. 



602 NEW-GROWTHS. 

known as rhinophyma, rhinoscleroma is readily differentiated by the 
softness and compressibility of the acneiform affection and its evident 
vascular and glandular composition. (Cf. Chapter on Gangosa.) 

The ulcerations of epithelioma have a more circular outline, a 
more elevated edge, and occur in persons of a more advanced age. 
Keloid, if found in the situation of rhinoscleroma, does not ulcerate. 

Treatment. — The method of relief thus far employed is a total or 
partial extirpation of the neoplasm. Kaposi speaks of dilatation of 
the nares, where there is actual or threatened nasal occlusion, by 
means of laminaria and compressed sponge. Both excision by the 
knife and destruction by caustics have been found to secure merely 
temporary benefit, as the growth is reproduced with rapidity. 

Prognosis. — The future of the patient is grave. The disease not 
only persists and recurs after operative interference, but also may 
endanger life by obstruction of the nostrils. Zeissl's case proved 
fatal ten years after the disease first appeared. 



TUBERCULOSIS CUTIS. 

Tuberculosis is one of the most common, formidable, and destruc- 
tive of the great scourges of the human family. It may attack either 
primarily or secondarily any organ or tissue of the body. The skin 
is not rarely the seat of its ravages, and when extensively involved 
the results are in the highest degree disfiguring and repulsive. 

The consequences of tuberculous invasion of the skin are usu- 
ally declared early in life, because in those periods the skin is most 
easily invaded, and also because at these ages the habits and environ- 
ment of the individual are conducive to the occurrence of the accident. 
Tuberculosis of the skin may be the result of general infection of the 
body ; or may, on the other hand, be the starting-point of such infec- 
tion. In either event the disease is always originally acquired by 
infection and not by inheritance. Children are rarely, if ever, born 
tuberculous. The coincidence of several members of one family ex- 
hibiting evidences of the disease is most readily explicable by the op- 
portunities for infective accidents furnished in such families. 

In the pages which follow no attempt is made to revert to the 
remarkable and instructive history of the gradual acquisitions of 
science on the subject of this disease. Neither within these limits is 
it desirable to indicate the several conditions which in their relations 
to this subject have been confused in the past, and the names of which 
have served as titles for chapters on cutaneous disorders. It will be 
sufficient if the results obtained from the vast and valuable labors of 
the pathologists and clinicians of the last decade be concisely set forth 
with a view to the simplest systematic conception of the subject. 1 

1 In the preparation of this chapter valuable aid has been rendered by the 
symposium on the subject prepared at the request of the Council of the Ameri- 
can Dermatological Association, by James C. White, of Boston; John T. Bowen, 
of Boston; and George Henry Fox, of New York. Boston, 1892. 



LUPUS VULGARIS. 



603 



The generally recognized clinical forms of cutaneous tuberculosis 
are: (1) lupus vulgaris ; (2) tuberculosis verrucosa ; (3) tuberculosis 
cutis orificialis; (4) scrofuloderma. 1 

LUPUS VULGARIS. 

(Lat., lupus, a wolf.) 

The symptoms of lupus vulgaris are both numerous and diverse, 
a fact which may account for the many names which have been ap- 
plied to its different manifestations, and which with few exceptions 
are descriptive merely of certain external features. 

The lupous infiltrate may be limited to small areas or diffused 
over an entire region of the body. It may be first apparent in pin- 
head- to bean-sized flattened maculations (Lupus Maculosus, Lupus 
Planus), from which later may be developed papules, tubercles, or 
nodules of equal or somewhat greater size, rising above the general 

Fig. 110. 




Lupus vulgaris. 



level of the skin and often perceptible within its. mass by palpation 
(Lupus Nodosus; Lupus Tuberculatus, Elevatus, Tumidus, Non-exe- 
dens, Non-ulcerosus). 

1 Erythema induratum is added to this group as it is accepted by the majority 
of observers to be a manifestation of tuberculosis of the skin. A group of diseases 
probably due to the toxines of the bacillus of tuberculosis are described in a sub- 
sequent section. Lichen scrofulosorum is placed in the latter group, though by 
several investigators it is believed to be a true tuberculosis of the skin, yet strong 
evidence can be brought forward to prove its toxic rather than local bacillary 
origin. 



604 



XEH'-GIiOWTHS. 



As in syphilis in the course of which, though almost every one 
of the elementary lesions of the skin may be developed, there is a dis- 
tinct predominance of the papule and tubercle, so in lupus vulgaris 
the type of the disorder is shown in the lupous nodule, the " lupoma," 
as it is designated by some authors. 

A typical patch of lupus vulgaris of small size is dull-reddish or 
purplish in color, scale covered, moderately elevated and well-defined. 
It is of a softish, almost boggy consistency, yielding when pressed 
upon firmly with a blunt-pointed probe and readily penetrated by a 

Fig. 111. 




Lupus vulgaris. 



sharper instrument. Under the diascope the inherent brown color of 
the individual nodules of which the patch is composed is revealed. It 
may remain thus for many years without change, except a gradual 
increase in size. 

The changes within, about, and beneath these lesions furnish prac- 
tically the clinical pictures of lupus vulgaris. Thus there may be 
extensive oedema, thickening, hypertrophy, hyperplasia (bouffissure) , 
pachydermia, even telangiectasis, and an accompanying lymphangitis 
or lymphadenitis (Lupus Hypertrophicus. Papillosus, (Edematosus, 
Elephantiaticus, Tumid us, Exuberaus, etc.). In many of these cases 
the prominent symptom which has suggested these names to the older 
writers is in fact a simple inflammatory swelling, due only indirectly 
to the lupoid involvement of the skin, a fact which can be recognized 
after any efficient treatment of an extensive plaque of lupus of the 



LUPUS VULGABIS. 605 

face, the subsidence of the swelling being one of the most conspicuous 
of the immediate results of the treatment. 

Involution of the lupoma, or of tissue infiltrated with lupoid cells, 
occurs by resorption of that material, by fibroid metamorphosis, and 
by ulceration. These several changes separately or together furnish 
other clinical pictures of the disease. Thus the lupus-lesion or patch 

Fig. 112. 




Lupus vulgaris in a colored patient. 

may furnish scales, w T hitish, dirty, yellowish brown, or even glistening, 
the epidermis above and about becoming wrinkled. This process may 
be central or peripheral as respects patch or lesion, leaving eventually 
a cicatriform depression in the skin (Lupus Exfoliativus, Lupus 
Psoriasiform^, "Lupus-psoriasis"). When a fibrous metamorphosis 
occurs a sclerotic mass occupies the site of the former lupoid tissue, 
which in some cases progresses to extension of the lupoid patch in 
consequence of the further production of the toxines of the bacilli in 
the site affected ; and in others produces cicatriform tissue resembling 
that left after involution without ulceration of the gumma of syphilis 
(Lupus Sclerosus, Sclereux, Fibrosus). 

In the degenerating forms of lupus, ulceration may begin by 
breaking down the epidermis over the lupous tissue or by a more or 
less rapid transformation of patch or lesions into a cheesy semi-puru- 
lent mass of detritus. When pus is freely formed, whether super- 
ficially or deeply, crusting ensues, the debris of epidermis being entan- 
gled with the desiccated secretions. These crusts are variously col- 
ored, and differ in thickness with the severity of the degenerating 
process beneath. The oval or circular ulcers which furnish them are 
usually well defined, though irregular as to the margin, shallow, thin- 
edged, and flattish; and their floors are dirty-reddish or purplish, 



606 



XE1V-GEOWTHS. 



indolently granulating, furrowed, hemorrhagic, or, when cicatrization 
is in progress, healthy. The destruction produced by involution of a 
lupous patch may be both by resorption and ulceration in the same 
subject and at the same time. The two processes may also coincide 
with an outbreak of fresh lupous tubercles, which later may develop 
at one point or another of the patch undergoing involution, probably 
from emigration of bacilli at the point of advance. In other cases 
lupus may spread by the formation of fresh nodules and plaques sep- 
arated by islets of sound skin from those previously degenerated. 
When the ulceration advances it may be superficial, deep, or have 







Fig. 


113. 












■ 




%-' ' 








^KP 


- 






































% 





























Lupus vulgaris serpigiuosus. 

other peculiarities, and be subject to other accidents of the ordinary 
process of ulceration whence the names Lupus Serpigiuosus, Profun- 
dus, Superficialis, Gangrcenosus, Exulcerans, Rodens, etc. Lupus 
Crustosus and Rupioides are terms descriptive merely of the incrusta- 
tions which form in some cases. Exuberant granulations elevating 
the floor of the ulcer may produce the condition termed Lupus Fun- 
gosus, Lupus Fungoides, Lupus Vegetans. Lupus Keloides indicates 
a cicatricial overgrowth of the scar-tissue left after any one of the sev- 
eral conditions described above. 

One of the most conspicuous features of lupus vulgaris is its essen- 
tially chronic course. It requires far more time for its complete 
evolution than either syphilis or carcinoma ; and in this point is best 
compared with lepra. For a quarter of a century a lupus-patch may 
be limited to a space no larger than the palm of the hand, and exhibit 
some evidence of activity during the greater part of that period. 



PLATE XXXII 




Lupus Hypertrophieus. 




Lupus Vulgaris of the Leg. 



LUPUS FULGABIS. 607 

Lupus of the Face. — Here the first manifestation is the so-called 
primary efflorescence, exhibited on one or both cheeks, nose, or cheek 
and nose, as a dull-colored macnlation or minute nodule, often long 
unnoticed, or as a finger-nail-sized, purplish thickening of the skin. 
Extension may then occur by multiplication of the lesions, or by 
spreading of the single, patch, the central parts wasting or cicatrizing. 
The contracture of the irregular scars thus resulting may produce an 
ectropion of the lid or lip, and with this is often seen the " bouffis- 
sure" of the features already described. Crusting and ulceration 
may be conspicuous or well-nigh absent features. Gradually the sub- 
cutaneous tissues become involved. 

The nose, after absorption of the lupous tissue, may become 
shrunken and retracted to a miniature of its former dimensions, its 
tip being noticeably reduced to a sharp point, producing thus a charac- 
teristic deformity suggesting the beak of a parrot. In other cases 
the point becomes bulbous, flattened, livid, and knobbed, with a thick- 
ened septum and distorted alse, an isolated patch or two of lupous 
infiltration showing in the neighborhood of the cheek on one or both 
sides. The last described condition may lead by degenerative proc- 
esses to the first, but is more commonly noticed as a less severe and 
more localized involvement of the face, which may terminate, in fav- 
orable cases, without the severe mutilation first described. 

The subcutaneous tissue, mucous membrane, cartilages, and bones 
may be destroyed ; and in place of the nasal organ itself there may be 
left eventually two ovoid cavities in the face, separated merely by the 
posterior flange of the septum. 

Often large portions of the skin of the head (cheeks, lips, nose, 
eyelids, chin, ears, brow, and neck) become altered by the lupous 
growth. The resulting thickening produces a marked and character- 
istic deformity, reducing the openings of the mouth and lids to nar- 
row slits, interfering with vision, speech, and mastication, and pro- 
ducing a marasmus from these causes alone, before there is ulcera- 
tion at any point. 

The ravages of the disease are at times frightful in severity ; not 
merely in consequence of the destructive ulceration to which it tends, 
but from the deformity left by awkward attempts at repair. The en- 
tire surface of the head may be thus converted into a hideous travesty 
of humanity, while yet its possessor is left with all vital organs and 
functions apparently unimpaired. 

The upper lip, when involved, becomes first swollen, fissured, 
hemorrhagic, and crusted; and a granulating surface indicates ex- 
tension of the disease to the adjacent mucous surface. Later, if the 
ulcer heal, the mouth, by contracture, is reduced to a repulsive-look- 
ing slit or chasm in the face, permanently retracted, and either open 
or closed. The gums, lining membrane of the lips, velum, and hard 
palate may also be granulating, eroded, or whitish, when the exfo- 
liated epithelium is in situ. Ulceration and cicatrization here also 
produce deformities interfering with the function of the parts, 



608 NEW-GBOWTHS. 

aphonia, for example, resulting from the operation of these causes in 
the larynx. 

Lupus of the Ears may be symmetrical in development, or affect 
but one auricle. As in eczema, a favorite point of election is the 
lobule, which, with or without tumefaction of the whole organ, be- 
comes a pyriform, purplish, dependent tumor, agglutinated speedily 
to the cheek. Later, when ulceration occurs, the auricle may disap- 
pear or be reduced to a shrunken shell of its former state, the exter- 
nal auditory meatus being, by the same process, occluded. 

Lupus of the Trunk is, as a rule, more extensive and less destruc- 
tive than lupus of other parts. Giant areas over the loins, hips, 
and belly may be involved in superficial, serpiginous ulceration, the 
centre healing as the peripheral ring spreads. In these cases it is 
even more difficult than in others to insure cicatrization. 

Lupus of the Genital Region may occur in both sexes, and then, as 
a rule, has extended thither from affected areas of the adjacent 
integument. It is one of the rarest of the locations involved. 

Esthiomene (so-called "Lupus of the External Genital Organs of 
Women").- — In the year 1849 Huguier published a report of cases 
under the title of esthiomene, which have been the basis of a concep- 
tion widely prevalent since that date that lupus of the vulva presents 
certain peculiarities not displayed by the same disease elsewhere. 
The subject has been restudied with special care by several observers, 
including myself, 1 and by Taylor, 2 of New York. Lupus is among 
the exceedingly rare affections of the external genitalia of women, and 
where existing does not in any special way differ from its manifesta- 
tions in other regions of the body. The " esthiomene " of Huguier 
and his followers is a complexus of differing disorders, including cases 
of syphilitic sclerosis, secondary lesions, and gummata; and hyper- 
trophies of the genital organs due to chronic " chancroid," trauma- 
tisms, and inflammations of a simple character aggravated by filth. 
It is not known to be a tuberculosis of the vulva, though it is possible 
that some tuberculoses may have been included in the category. 

Lupus of the Extremities is remarkable for its interference with 
the mobility of the smaller bones of the hands and feet, as a result of 
rigid cicatrices, and also for the production of caries and osseous ne- 
crosis. Mutilating effects are thus produced by loss of phalanges, 
and also by shortening of the hand or foot after the destruction of 
bone. Elephantiasic enlargement of such organs as the hands and 
feet thus corresponds to the livid tumefaction seen occasionally in the 
face. Thickenings, ridges, knobs, nodules, warty excrescences, ul- 
cers, crusts, and callosities are often commingled, and in patients of 
mature years strongly resemble some forms of vegetating and ulcerat- 
ing epithelioma. 

Lupus of the Mucous Membranes may or may not mean extension 
of the disease from an affected adjacent integument. The lupous 

l J. of C. and G. U. D., 1889, vii., p. 129. 
2 Ibid., 1891, ix., p. 201. 



LUPUS VULGARIS. 609 

nodule, in consequence of warmth and moisture, is here transformed 
into a moist papillary outgrowth, or externally granulating patch 
which may ulcerate and cicatrize. The borders of such an affected 
area are well defined, and its surface is reddish and florid, quite pallid, 
white and glistening, or of a dirty grayish-white color where the in- 
vesting epithelium is loosened but not yet detached. 

The soft is more often involved than the hard palate, but these 
parts with the tongue, larynx (epiglottis, interarytenoid fold), and 
gums may be extensively invaded. Often for from two to five years 
the disorder may make no apparent advance, being limited to patches 
of red, swollen, coarsely granulating, whitish or glistening mucous 
membrane, with ulcerating and cicatricial processes slowly resulting. 
The lymphatic glands beneath the jaw and in the subclavian region 
may be simultaneously enlarged. In connection with the characteris- 
tic lupoid nodules grayish growths of the character of small tumors 
may be recognized in the larynx, with the result of partial occlusion 
of the rima glottidis. Patients may suffer from apical pulmonary 
tuberculosis, presumed to be the result of extension of the disease from 
laryngeal lupus. 

"Lupus Demisclereux de la Langue." — Leloir 1 pictures and de- 
scribes the features in the case of a girl fifteen years of age, with 
lymphatic adenopathy, typical lupoid nodules about the nose, and 
characteristic " parrot's beak deformity " of the latter. The middle 
of the dorsal surface of the tongue displayed smooth, pea-sized and 
larger sclerotic nodules, grayish yellow, firm and softish, separated by 
furrows, and non-ulcerative. The palate, uvula, and larynx were in- 
volved. Tubercle-bacilli were recognized and cultivated in series, 
and inoculation of the cultures produced tuberculosis in guinea-pigs 
and a rabbit. 

TUBERCULOSIS CUTIS VERRUCOSA. 

There are several forms of tuberculosis of the skin in which lesions 
differing both in appearance and career from those described in con- 
nection with lupus vulgaris have been demonstrated to be the result 
of the encroachment of bacilli of tuberculosis upon the integument. 
The lesions exhibit for the most part a verrucous or warty appear- 
ance, and are illustrated well in the most distinctive clinical member 
of the group, the anatomical tubercle. In 1884 bacilli first were dis- 
covered in its mass, and in the year 1886 Eiehl and Paltauf pointed 
out the connection of this lesion with cutaneous tuberculosis. 

Verruca Necrogenica {Post-mortem Tubercle, Dissection-tubercle, 
Anatomical Tubercle). — Verruca necrogenica is a vesiculo-pustular 
or wart-like lesion of cutaneous tuberculosis, situated usually on the 
hands, and resulting, for the most part, from contact with bodies 
of the dead. 

This lesion was named verruca necrogenica first by Wilks. 2 It 



Internal Atlas, 1889. 

Guy's Hospital Eeports, s. 3, viii., p. 263. 



39 



610 



NEIV-GEOWTHS. 



occurs on the fingers (especially on the dorsum of the thumb and of 
the index finger) of those engaged in the habitual handling or dissec- 
tion of cadavers, and results from such professional contacts, from dis- 
section-wounds, and from all accidental inoculations with tuberculous 
virus. Cases are reported in which the lesion has had a non-cadaveric 
origin. It begins at the site of an abrasion or wound as a vesico-pus- 
tule, with deep-seated base and reddish or reddish-purple areola. 
This is productive of a burning, smarting, or pruritic sensation. The 
lesion accomplishes a period of bursting and crusting, which may be 
followed by complete involution. Several isolated or grouped pap- 
ules, nodules, or tubercles may be formed, one or a patch of several 
being subsequently covered with villosities or undergoing atrophic 
changes over an area several inches in diameter. Dermatitis and 
suppuration, very rarely ulceration, may complicate the process, 
though at times the first symptom of infection is an ulcer forming at 
the site of a cicatrix. The typical so-called " anatomical tubercle " 
is indurated and horny. A pigmented verrucous papule or tubercle 
very slowly forms, which may become fissured at one or more points. 

Fig. 114. 




Pig- 



The characteristic lesion is the thickened, indolent, more or 1 
mented and fissured, split-pea to bean-sized wart, usually 
found on the finger of the anatomist. This may persist as an appar- 
ently innocuous lesion for months or years, or suddenly assume a for- 
midable aspect. 

In other cases grave symptoms result, either in the involvement of 
the deeper tissues (subcutaneous, thecal, tendinous, periosteal), or in 



TUBERCULOSIS CUTIS VERRUCOSA. 611 

the production of erysipelas, pyaemia, septicaemia, or gangrene. Sur- 
geons divide these cases into mild and acute varieties, according to the 
symptoms exhibited. The records of the medical profession in almost 
every one of the large cities of every country contain the names of one 
or more eminent men whose lives have been sacrificed in this manner. 
In a few instances the local process has been followed by generalized 
tuberculosis. 

Tuberculosis Verrucosa Cutis (Biehl and Paltauf) (Lupus Scle- 
rosus, Lupus Verrucosus, Scrofuloderma Verrucosum; Fr., Lupus 
Papillaire Verruqueux; Lupus Sclereux). — The lesions of this form 
of cutaneous tuberculosis occur often on the flexor aspect of the lower 
forearm, but also in other regions of the body, such as the integument 
covering the inner malleolus and the backs of the hands. The 
plaques are insensitive, brownish red, movable, small-coin- to palm- 
sized, single or multiple, distinctly circumscribed, ovoid or scalloped 
in outline, and usually covered with minute pustules, fine pointed 
vegetations, and thin crusts. A characteristic violaceous halo com- 
monly surrounds the whole. When healing occurs a smooth and 
scaling scar results. In those cases the papillary layer of the skin is 
chiefly involved. 

In the papillary layer of the corium the inflammation results in 
the production of numerous minute abscesses. Caseating nodules con- 
taining tubercle-bacilli, giant-cells, and epithelioid cells are com- 
mingled with the abscesses. In some cases tubercle-bacilli are num- 
erous ; in others their detection is difficult if not impossible, as in 
verruca necrogenica. 

The disease is to be' most carefully distinguished from cutaneous 
blastomycosis, the lesions of which it closely resembles. Here a his- 
tological examination is essential. 

The disorder is said to be especially frequent of occurrence in 
those handling the dead or living bodies of animals. 

Other Verrucous Tuberculoses. — An interesting series of morbid 
phenomena is presented when, for special reasons (proximity of tuber- 
culosis of organs other than the skin, accidents of position and ex- 
posure, influences that escape detection), sites of tuberculous infec- 
tion, whether primary or secondary in order, exhibit peculiar special 
symptoms : 

Tuberculosis Papillqmatosa Cutis (Morrow's type) is by some 
authors assigned to verrucous tuberculosis. In these cases ex- 
uberant, soft, and florid excrescences rise to the height of one or two 
centimetres above the general level, closely packed together, with indi- 
vidual elements separated by deep fissures, the whole bathed in a puri- 
form mucus concreting in dark crusts. 

Fibromatosis Tuberculosa Cutis (Biehl). — In these cases there 
is not merely a papillomatous, but often a sclerotic growth found on 
the lips, nose, cheek, or about the anus or other mucous outlets of the 
body, interspersed with verrucous lesions, vegetations, and small shal- 
low ulcers. The tuberculous masses may be in the form of tumor- 
like bodies or thickenings of the subcutaneous tissue. 



612 NEW-GROWTHS. 

Elephantiasis Tuberculosa Cutis is a term applied to gigantic 
overgrowths of the integument complicated by lymphatic occlusion. 
In these cases there has usually been a blocking of the lymph- 
channels by an infarction produced by leucocytes charged with tuber- 
cle-bacilli. 

It is chiefly important to note in this connection that accidental 
inoculations with tuberculous material produce in different cases dif- 
ferent clinical results, the essential part of the process being the trans- 
ference of tubercle-bacilli. These infections are far more common 
than is generally understood. They occur in both the young and the 
old. Fox, of London, has reported such instances at the ages of sev- 
enty-two and eighty-two, respectively; and Marmaduke Shield has 
seen cases of general tuberculosis of the aged, resulting from these 
accidents. 

TUBERCULOSIS CUTIS ORIFICIALIS. 

The clinical forms included under this title are those once sup- 
posed to be the sole manifestations of cutaneous tuberculosis. The 
title " tuberculosis of the skin " was, in fact, applied exclusively by 
many writers to the lesions observed by Kaposi, Jarisch, Chiari, 1 and 
others. These were indolent, oval or circular, shallow, discrete, red- 
dish-yellow, granulating ulcers, often covered with thin crusts, occur- 
ring about the mucous orifices of patients affected with pulmonary 
tuberculosis (lips, anus, and vulva) and with development of miliary 
tubercles in the adjacent mucous tract. Tuberculous lesions of ul- 
cerative type on the ala? of the nose, over the lips, and about the ears, 
have been recognized in association with laryngeal, palatal, oral, pul- 
monary, and intestinal tuberculosis. 

In the case of a patient in advanced pulmonary tuberculosis, lately 
seen by us, there was a tuberculous ulcer near the anus, and also a 
well-defined patch of infiltration in near proximity, highly sugges- 
tive of some of the forms of lupus. 

Acute Tuberculosis of the Skin has been described under different 
titles (dermatitis tuberculosa acuta, 2 tuberculose pseudoulcereuse) 
by Heller and Gaucher. In the case of children macules, vesicles, 
bulla?, papules, and pustules, terminating in deep, crusted, circi- 
nate ulcers, accompanied by caseation of neighboring glands, were 
found to contain bacilli ; and inoculations of cultures resulted in dis- 
tinct tuberculous infection. These cases scarcely justify their sep- 
arate classification. They are properly placed with the clinical forms 
of disease termed, for provisional purposes, scrofulosis of the skin. 

Exanthematic Miliary Tuberculosis of the Skin may follow the ex- 
anthematous fevers in children. The lesions are multiple, indolent, 
dull brownish-red tubercles, acuminate, situated in or near the cutan- 

1 Vierteljahr., 1879, vi., p. 269. 

2 E. Brunsgaard, ArcMv, 1903, Ixxii., p. 227 (abstr. B. J. D., 1904, xvi., p. 151). 
A report of a case of almost universal dermatitis in a woman aged 63 years. 
General enlargement of the lymph glands was present. In both the glands and 
sections of the skin a tuberculous structure with tubercle bacilli was demonstrated. 



SCBOFULODEBMA. 613 

eous follicles and suggesting the lesions of acne papulosa. When 
in process of degeneration they form rounded, circular, or polygonal, 
sharply cut ulcers having a violaceous border, an irregular, granular 
floor, and a scanty sero-purulent discharge. Miliary nodules are to be 
seen both on the floor of the ulcerative surface and in the periphery 
of the lesion. They contain tubercle-bacilli. 

This disorder occurs, as a rule, in those exhibiting other and un- 
mistakable symptoms of tuberculosis. If the lesions be solely cutan- 
eous, healing may result. 

SCROFULODERMA. 

(Lat., scrofa, a sow.) 

The term scrofula, or struma, has been long and loosely applied 
in general medicine for the purpose of designating a number of dis- 
eases the real significance of which was unknown, their points of re- 
semblance being greatly outnumbered by their specific differences. 
The researches of the last twenty years have been steadily and con- 
tinuously restricting this list in almost every department of medicine. 
Many of the disorders once supposed to be scrofulous are now known 
to be syphilitic. In orthopaedic surgery a number of joint-affections 
once believed to be incontestably of strumous origin are known to be 
producible by traumatism exclusively. And in dermatology no less a 
broad advance has been made since the day when eczema, psoriasis, 
and acne were described as evidences of scrofula. 

The term scrofuloderma is applied now only to those forms of 
cutaneous tuberculosis in which the skin is involved secondarily by 
direct extension of the process from tubercular glands, or other foci 
of tuberculosis beneath the skin. By the term scrofula Billroth recog- 
nized a condition in which there occurs at any point in the body 
where irritation has operated an indolent inflammation, which 
persists after such irritation has ceased, which frequently terminates 
in suppuration and caseation, and which subsequently rarely pursues 
a hyperplastic career. If with this be conjoined inflammation and 
caseous infiltration of the lymphatic ganglia, or of the subcutaneous 
connective tissue, amyloid degeneration of one or several of the vis- 
cera, tumefaction of the belly, chronic keratitis, ophthalmia, otorrhcea, 
or coryza, a chronic arthritis (white swelling), a pasty, dirty colored 
and thick or delicate and transparent skin, exhibiting cicatrices of old 
abscesses or ulcers, and a voluminous nose overlooking thick, everted 
lips, the general picture of the scrofulous patient may be considered 
complete. The recognition by Robert Koch of the etiological im- 
portance of the bacillus tuberculosis in tuberculous disease, and the 
demonstration of the presence of these micro-organisms in a number of 
lesions heretofore regarded as " scrofulous," have established their sci- 
entific position beyond controversy. 

The scrofulodermata are characterized by the occurrence of patho- 
logical processes in the skin, lymph-glands, or periglandular tissues, 
which betray evidence of the tuberculous process. They usually be- 



614 



NEW-GROWTHS. 



gin as firm, well-defined subcutaneous nodules, similar in type to the 
syphilitic gumma, which gradually enlarge, become attached to the 
skin, subsequently degenerate, exhibit characteristic ulcers, and usu- 
ally terminate by no less characteristic cicatrices (" Gommes Scroful- 
euses," " Gommes Scrofulo-tuberculeuse>,'* " Scrofuloma," Cold Ab- 
scess of the Skin). 

The typical and commonest form of scrofuloderma is encountered 
about the face and neck, where the lymphatic glands have long been 
tumid, and are either dense or doughy to the touch. Usually this con- 
dition is reached very slowly ; often months and years are required 
for its production. The glands may be as small as almonds or as 

Fig. 115. 




Scrofuloderma. 



large as the closed fist. Gradually a characteristic dermatitis en- 
sues in the skin which is superimposed. It becomes purplish and 
thinned, and finally yields, giving exit to a sero-purulent fluid min- 
gled with caseous matter and blood. The pus-corpuscles of this fluid 
examined under the microscope are seen to be poor in protoplasm. 
Fistulous tracts and sinuses result, which undermine and perforate 
the skin, resulting in the production of a chronic discharge and char- 
acteristic ulcers. The latter are far more remarkable for their bor- 
ders and bases than for their floors. They are usually linear, occas- 
ionally elongated and oval, almost never circular. As a result, their 
uneven floors, covered with pallid granulations and a watery pus, 
often are hidden beneath their inverted, tumid, and uncolored edges ; 



SCBOFULODEBMA. 615 

or the latter may be thinned, stretched over a fistulous pocket, and red- 
dish or purplish in color. Their bases usually are attached deeply to 
the subcutaneous tissue, and are firm or soft, never densely indurated. 
The resulting crusts are thin, tenacious, reddish or brownish, and, like 
the ulcer, often linear, rarely bulky, never rupioid. The resulting 
cicatrices are corded, depressed in irregular lines or bands, and often 
alternate, with equally irregular nodules (scrofulous gummata) where 
the degenerative process either has been arrested or is still in activity. 

Rarely enormous ulcers originate in the manner described above, 
which dissect out vast areas of subcutaneous and intramuscular tissue 
in the neck and even the extremities, in the course of which cartilage, 
bone, and periosteum are melted away. Usually but a few of these 
points of degeneration, from two to six, are exhibited in one patient. 

Another type of scrofulous gumma of the skin begins as a subcu- 
taneous nodule on the back or over the extremities of scrofulous chil- 
dren, the career of which is practically that outlined above. It differs 
chiefly from the lesion more or less directly connected with the lym- 
phatic glands, by reason of its relation with lymphatic vessels distri- 
buted to a deeper and possibly distant tuberculous focus. 

According to Unna, there is a " dry " form which originates in the 
action of tuberculous toxines in the granuloma ; and a " wet " form, 
the product of reaction of the nutrient channels and the resulting 
oedema. Tubercle-bacilli have been recognized in a few cases only, 
but their toxines have given rise to the pathological changes. 

Tuberculosis Fungosa Cutis 1 (Riehl)^ — A group of cases are recorded 
in which tumors resembling those seen in mycosis fungoides and 
sarcoma occurred intermingled with other lesions. Histologically 
and bacteriologically these have been proven to be tuberculous as the 
lesions are produced in the skin from infection with the tubercle 
bacillus by direct contiguity from an infected bone, muscle, or other 
structure beneath ; they properly belong to the scrofulodermata. On 
account of its striking clinical aspects the disease is described separ- 
ately. It is essentially an infiltrating form of cutaneous tuberculosis 
with excessive granulations forming fungous tumors and having in 
addition ulceration, crusts, and fistulous tracts in which cheesy de- 
generation is abundant. 

Tuberculous Dactylitis, observed generally in children, is character- 
ized by bulbous extremities of the fingers and toes, the skin cov- 
ering the same being at times the seat of infiltration and thickening. 
White believes this process to be more common than that occurring 
in dactylitis syphilitica. 

Suppurative Tubercular Lymphangiectasis (Hallopeau and Goupil) 
is a condition in which scrofulo-tuberculous gummata, in small-nut- 
to egg-sized tumors, form along the lymph-vessels, of the lower ex- 
tremity particularly. When such a tumor breaks down it furnishes 

1 Pick, J. C. D., 1904, xxii., p. 305. A review of other cases and report in full 
of two new ones. 



616 NEW-GROWTHS. 

the typical picture of the scrofulous ulcer, with its cheesy and watery 
pus, its thin edge, and its indolent career. In these rare cases bacilli 
have been recognized in the secretion. 

Tuberculosis Cutis Serpiginosa Ulcerativa is a term relating to a rare 
group of lesions in which brownish-red nodules, pea- to bean-sized, 
degenerate in the course of weeks or months until there results a 
centrifugally spreading, ovoid or roundish, even horseshoe-shaped ulcer, 
grayish yellow in hue and overspread with smaller .cicatrices. In- 
stead of nodules, the first lesions may be circumscribed areas of infil- 
tration. The involved surface may be extensive, even larger than 
the two palms, and may coexist with secondary foci of involvement. 
Visceral and pulmonary tuberculosis may result. The resemblance 
of the large spreading patches to a serpiginous syphiloderm is striking. 

Lymphangitis Tuberculosa Cutanea (Besnier, Lejars). — The lym- 
phatic vessels of the skin may be either primarily or secondarily 
invaded with tubercle-bacilli, and in either event linear lesions form 
corresponding to the lymphatic trunks, or there develop tuberculous 
nodules or warts, dermic or subcutaneous in situation, which event- 
ually ulcerate and discharge pus, blood, or lymph. At times a retic- 
ular network results, with fistulous sinuses. Several of the lymphan- 
giectases have been demonstrated to be tuberculous in character. 

Etiology of Tuberculosis Cutis. — Accidental inoculation of tuber- 
culosis may occur at all ages and in all sexes, the infective material 
gaining access to the economy in the large number of instances by 
the medium of the lymphatics. There is, however, ampler oppor- 
tunity for such transmission among the members of any family in 
which pulmonary tuberculosis exists ; hence the widespread belief in 
the heredity of the disease. Attention has, however, been already 
directed in these pages to the striking fact that children are rarely 
born into the world tuberculous ; and to the possibility that all cases 
of reputed inherited tuberculosis were acquired by direct infection 

Given, however, an infective micro-organism, the soil upon which 
it may flourish most favorably is of paramount interest in an etiologi 
cal view. The young, the delicate, the cachectic furnish such a cul 
ture-field. With these must be included, as favoring such accidents 
the mode of life of the very poor, the filthy, and the degraded. Thus 
lupus vulgaris is originally developed in the majority of all cases 
during the first decade, between the third and sixth years of life 
rarely after the thirtieth year, for the reasons above given. The sig- 
nificant fact in this connection is that at this period of life the child 
often deprived of the constant care of the mother by the demands 
made by a still younger infant, untaught in the simplest rules of 
cleanliness, picking and scratching the face after miscellaneous con- 
tacts of the fingers with all sorts of material, is exceedingly liable to 
inoculate the skin of the face with tuberculous virus, if there be vic- 
tims of such disease occupying the same apartment or house. It is 
significantly first upon the face in these early years, and next over 



SCROFULODERMA. 6 1 7 

parts such as the extremities or the genital region, to which the ex- 
posed hands have been carried, that the early symptoms of lupus vul- 
garis are betrayed. Further, it is noteworthy that well-marked cases 
are more frequent among the poor, the filthy, and the degraded than 
among the comfortable and cleanly. The prevalence of the disease in 
public as contrasted with private practice is conspicuous in all sta- 
tistics. 

As throwing additional light upon the question of childhood-infec- 
tion, it is to be noted that other forms of tuberculosis occur at any 
period of life and in both sexes, when the accident of infection oper- 
ates. Besnier, Little, and others, for example, report cases of lupus 
resulting from tuberculous infection in vaccination; Fournier, an 
instance in which a young woman was infected during the piercing 
of the ear for the insertion of earrings ; Jadassohn, a case in which the 
tuberculous virus was inserted by tattooing ; and Strauss, the history 
of a student who was wounded by a rapier in a duel, and as a result 
developed lupus in the site of the wound ; Brums, an instance of in- 
fection by inoculation with a hypodermic syringe used for injecting 
morphine. In verruca necrogenica and warty growths of the same 
nature it is contact with the bodies of the dead or with tuberculous 
matter in any form that determines the result. The aged with 
tuberculous lesions upon the backs of the hands, middle-aged persons 
with other evidences of cutaneous affection, actually suffer from gen- 
eralized tuberculosis as a result of the accident. All varieties are 
due to the local action of tubercle-bacilli. Tuberculosis verrucosa 
cutis results in the majority of cases from direct inoculation from 
external objects containing tubercle-bacilli. 1 It is reported frequently 
among the miners from the district around Dortmund. 2 Lupus vul- 
garis also is produced in this way, but frequently the infection is 
brought to the skin through the lymphatics. In scrofuloderma the 
bacilli find their way to the skin by direct extension from beneath, 
while tuberculosis cutis orificialis is an example of auto-inoculation, 
and is usually secondary to visceral tuberculosis. 

What may be said of the causes of lupus vulgaris relates also to 
scrofuloderma, which, while occurring in both sexes and at all ages, 
is more frequent in early life because of the susceptibility of the tis- 
sues at those periods. 

The soil fittest for scrofulodermatous manifestation is that where 
well-known agents have been most efficiently at work. All causes 
which tend to impair the nutrition and vigor of the body are, to an 
extent at least, efficient in its development, including privation from 
sunlight, fresh air, wholesome food, exercise, and hygienic influences 
in general. It is common among prisoners, exiles, and in this coun- 

^assar, Derm. Zeitschr., 1903, x., p. 505 (abstr. B. J. D., 1904, xvi., 151). A 
report of two cases of tuberculosis verrucosa cutis in patients working with 
diseased cattle, the author concluding that these were examples of bovine tubercle 
bacilli inducing cutaneous tuberculosis in man. 

2 Archiv, 1904, lxx., p. 329 (abstr. B. J. D., 1904, xvi., p. 431). A report of 
166 cases occurring between the years 1889 to 1903 by Fabry and Schulze. 



618 NEW-GBOWTHS. 

try, among negroes and those of mixed blood. Consanguineous mar- 
riages are said to result often in strumous offspring. Lupus and 
other forms of cutaneous tuberculosis have frequently followed 
an attack of measles. 1 In many cases scrofuloderma is the sequence 
of other depressing medical diseases and surgical accidents. In cer- 
tain instances especially where it is limited to the neck, and accom- 
panied merely by a cervical or submaxillary adenopathy, scrofulosis 
is consistent with full vigor and nutrition of the body and all other 
evidences of sound health. 

Pathology of Tuberculosis Cutis. — Lupus vulgaris, tuberculosis 
cutis verrucosa, and scrofuloderma, as well as tuberculosis cutis orifici- 
alis (the one form hitherto recognized as tuberculous) are due to in- 
fection with tubercle-bacilli, and are practically identical histologi- 
cally with tuberculous lesions in other organs of the body. The dis- 
covery of bacilli in lupous tissue, first made by Koch, has since been 
verified by Doutrelepont, Weichselbaum, Meisels, Schuller, Lustig, 
and others. The striking resemblance first shown by Virchow be- 
tween a caseous miliary tubercle and a lupous nodule had, even be- 
fore Koch's discovery, pointed to an identity of origin. The result 
of inoculation of culture-fluids has given positive results. Lenz, 
Hiiter, Schuller, ourselves, and others have produced tuberculosis 
by introducing in rabbits granulations taken from lupus and other 
varieties of cutaneous tuberculosis. 

For a knowledge of the microscopic characters of cutaneous tuber- 
culosis we are indebted largely to the Germans. Virchow, Auspitz, 
Billroth, Lang, Kaposi, Klebs, Stilling, and Thin have contributed 
amply to the subject. 

The histological structure of the various forms of cutaneous tuber- 
culosis varies in minor particulars, but in essential features suffi- 
cient uniformity exists to enable the observer to discern that each is 
due to a similar exciting cause. Each is produced by the local ac- 
tion of the tubercle bacillus, and presents a cellular new-growth, vas- 
cular changes ranging from slight proliferation in the coats of the 
vessels to their complete obliteration ; and attenuation, hypertrophy, 
or complete destruction of the collagen. The sebaceous and sweat- 
glands, hair-follicles, and elastin all suffer alteration, even to destruc- 
tion. The epidermal changes in all are secondary, and include 
acanthosis, hyperkeratosis, parakeratosis, scaling, and at times even 
complete destruction by ulceration. The tubercular nodule in 
the skin resembles that found in other organs, and consists, essen- 
tially, of one or more giant-cells immediately surrounded by a num- 
ber of small, round cells, which have vesicular nuclei, and which are 
either mononuclear leucocytes or daughter plasma-cells (Unna). In- 
terspersed among these may be a few multinuclear cells, and surround- 
ing these is a zone of plasma- and connective-tissue cells. No vessels 

^damson, H. T., B. J. D., 1904, xvi., pp. 366-376. A full discussion with 
of 28 



TUBERCULOSIS CUTIS. 619 

exist in the nodule, and the fibrous elements are either attenuated or 
completely absent. The nodule is surrounded in the nodular form of 
lupus by a collagenous capsule. In another variety no limiting cap- 
sule is present, and the cellular hyperplasia spreads along the lymph- 
spaces, producing an even, brownish discoloration of the skin, in 
which case giant-cells are not numerous. 

Degeneration occurs in the nodule, as is shown by the cellular pro- 
toplasm becoming homogeneous and the nuclei incapable of absorbing 
stains normally. True cheesy degeneration seldom occurs in the skin, 
which fact might be accounted for by the relative scarcity of bacilli 
in most of these lesions. 

The cellular hyperplasia is composed of giant-cells, which are 
large, oval, round, or irregularly shaped cells, containing as a rule 
many peripherally placed nuclei and having a homogeneous centre; 
plasma-cells, which vary in size, are usually oval or oblong in shape, 
possess a large amount of protoplasm, and present an eccentrically 
placed vesicular nucleus; and small round cells, usually described 
as mononuclear leukocytes or daughter plasma-cells (Unna), which 
contain nuclei similar to the plasma-cell. In addition, some mast- 
cells are present, and in these the nucleus is surrounded by granules 
of protoplasm, which are identified by stains having metachromatic 
properties. Multinuclear cells are also present, and a large number 
of ordinary connective-tissue cells. Tubercle-bacilli are found most 
abundantly in the acute miliary variety of cutaneous tuberculosis; 
fewest in lupus vulgaris, in the lesions of which they are often diffi- 
cult to demonstrate. Giant-cells are most abundant in lupus vulgaris, 
while cheesy degeneration, common to internal tuberculosis, is more 
prevalent in the miliary variety. Bacilli may be found between the 
cells, but are found more often in giant-cells. Animal inoculations 
may be performed successfully in each variety, and they all react to 
tuberculin injections. 

Lupus Vulgaris occurs in two varieties, the nodular and the dif- 
fuse. In the former the tubercles above described are enclosed in a 
limiting capsule of collagen, while in the diffuse variety the infiltra- 
tion spreads evenly along the lymph-spaces without interruption, 
producing a diffuse infiltration. There is a tendency for the gran- 
uloma to be replaced by connective tissue, which at times multiplies 
to an excessive degree, producing a condition of elephantiasis. As 
the cellular infiltration progresses the normal structures of the skin 
are atrophied or destroyed ; collagen, sebaceous and sweat-glands, hair- 
follicles, and, finally, elastin all disappear. Proliferative changes 
may occur in the epidermis, in which marked down-growth (acantho- 
sis) of the rete into the corium results, producing the papillomatous 
variety of lupus, while with increased cornification verrucous forms 
occur. Pressure from below may rupture the epidermis, permit pyo- 
genic infection, and result in ulceration. (Edema, with accompany- 
ing parakeratosis and scaling, may be present. All these epidermal 
changes are secondary, however, and are in themselves not tubercu- 



620 NEW-GEOWTHS. 

Ions, the principal and characteristic changes being found in the 
corium. 

Tuberculosis Verrucosa Cutis is distinguished by having the 
tuberculous plasmoma located chiefly in the papillary layer of the 
corium. The usual structure of the tuberculous nodule may be dem- 
onstrated. Marked acanthosis and hyperkeratosis are also distin- 
guishing features. Miliary abscesses, produced by pus-cocci, may 
be found both in and beneath the epidermis. Tubercle-bacilli are 
usually more numerous than in lupus vulgaris and find their entrance 
from without. Both histologically and clinically this variety of 
tuberculosis is nearly identical with some forms of lupus vulgaris, 
and now often is classified as a manifestation of lupus vulgaris. 

Tuberculosis Cutis Orificialis. — In this variety both in the 
number of bacilli present and in the type of lesion, there is an analogy 
with miliary tubercle of other organs. Large numbers of typical, cir- 
cumscribed nodules are found deep in the corium ; bacilli are numer- 
ous and easily demonstrated ; the degenerative processes go on rapidly, 
the tubercles breaking down and coalescing to form masses of softened 
necrotic tissue which soon break through the epidermis to form an 
ulcer. About the borders of such necrotic areas new nodules are 
constantly forming, and the whole process is rapid, as in acute tuber- 
culosis of other tissues. Histologically it is composed of the usual tu- 
berculous plasmoma, its distinguishing features being the presence 
of large numbers of bacilli and also typical cheesy degeneration, which 
is not found in the other varieties. 

Scrofulodermata. — The scrofulodermata originate in the subcu- 
taneous tissues and involve the skin secondarily. The lymphatic 
glands or the tissues about the glands or lymphatic vessels become the 
seat of the tuberculous process, which runs a subacute course. The 
glands or peri-glandular structures finally break down into softened 
necrotic masses. Such areas of necrosis may remain indolent and 
superficial, or, in case a gland is involved, may be deep and extend 
by burrowing prolongations even to the bone. Sooner or later the 
skin over these softened masses becomes involved in a subacute in- 
flammatory process and gives way, producing the typical ulcer with 
soft, ragged, and often extensively undermined edges. Experimental 
inoculations and the presence of tubercle-bacilli have demonstrated 
these subcutaneous processes to be tuberculous. The number of ba- 
cilli present varies greatly, being much larger than in lupus, but 
much smaller than in the orificial forms of cutaneous tuberculosis. 
The relationship of the scrofulodermata to lupus is occasionally shown 
by the formation of typical lupous nodules near the border of these 
scrofulous ulcers, the result no doubt of inoculation of the skin with 
the discharge from the ulcer. The granuloma here consists of a dif- 
fuse plasma-cell infiltration with some giant-cells about the edges of 
the lesions. 

Diagnosis of Tuberculosis Cutis. — Epithelioma, though rarely re- 
sembling lupus vulgaris, is more often designated by that than by 



TUBERCULOSIS CUTIS. 621 

any other false title. Great confusion has arisen from the looseness 
with which several authors have furnished illustrations of "lupus 
exedens," which were really pictures of cancer. But the latter is 
rarely a disease of early life, and when of early occurrence may not 
persist to adult years; the reverse of which is true in the majority of 
all cases of lupus. The nodules of lupus are absent in epithelioma, 
and their evolution in the disease is slower, less painful, and, in ear- 
lier periods certainly, of deeper situation. The ulcer of epithelioma 
is more often denned and single; its edges whitish, indurated, and 
everted ; its floor uneven and glazed ; its secretion scanty and occasion- 
ally fetid; its base a mass of indurated tissue. Lupous ulcers are 
often ill defined and multiple; their edges soft and inconspicuous, 
neither everted nor undermined; their floors granulating and flat- 
tened ; their secretion relatively profuse and generally odorless ; their 
bases soft and pliable, though occasionally indurated. 

Tubercular, serpiginous, and ulcerative lesions of syphilis often 
resemble certain forms of lupus. In any doubtful case a history of 
infection, of other types of cutaneous disease, of mucous patches, of 
adenopathy, of abortions in women, etc., should aid in the recognition 
of syphilis. The suspected lesions should be examined carefully for 
the purpose of distinguishing characteristic lupous nodules in the 
patch itself or in the periphery of any exfoliating area. In the case 
of an adult a history of long-existing lupus may often be obtained ; 
and it is worthy of note that syphilis with exceeding rarity displays 
for long periods of time a single exanthematous lesion or aggregation 
of such lesions exclusively in one part of the body. Lupous ulcers, 
often multiple and isolated, insensitive, well- or ill-determined in 
outline (never reniform or horseshoe-shaped), with supple, low edges 
and reddish, smooth, hemorrhagic, granulating floor, covered with 
crusts like soiled parchment of uniform thickness, do not resemble 
those of syphilis. The latter are often painful, single, circular, and 
clean cut in contour, with firm, raised, infiltrated margins, and with 
offensive greenish and blackish crusts, resembling oyster-shells. The 
cicatrices of syphilis are elegant, smooth, delicate, superficial, circular 
and, after pigmentation has disappeared, dead white in color ; those 
of lupus are irregular, indurated, deforming, yellowish white and 
reddish yellow. Acquired syphilis is a disease of adult life; lupus 
commonly begins in childhood. 

The disks of psoriasis are distinguished from flat exfoliating 
patches of lupus vulgaris by the relatively large number of the former, 
by the nacreous lustre of the scales, the reddish hemorrhagic surface 
beneath, and the sites of election of the disks, usually on the extensor 
faces of the limbs. 

Lupus erythematosus is even more readily distinguished by its 
characteristics ; including the absence of nodules, ulcers, and crusts, 
the superficial character of the morbid process, the scaliness, and 
occasional symmetry of the patches. An intermediate form between 
lupus erythematosus and lupus vulgaris has been described, but most 



622 NEW-GROWTHS. 

cases so classed probably belong to the type called by Leloir " erythe- 
matoid lupus vulgaris," in which nodules are temporarily absent. In 
all such cases typical nodules of lupus vulgaris develop sooner or later 
and confirm the diagnosis. The two diseases, unfortunately some- 
what similar in name, are distinct in character. The so-called inter- 
mediate forms may be instances of flat and scaly epitheliomatous in- 
filtration going on to ulceration. 

In acne rosacea with a bulbous condition of the tip of the nose the 
redness is vivid ; and the telangiectasia complications, with the sebor- 
rheic flux, are conspicuous points of difference from lupus vulgaris. 
There is, further, no ulceration and little scarring, and the patients 
have usually suffered from the disease only after arriving at maturity. 
The mucous surfaces are also spared. 

The diagnosis of verrucous growths of tuberculous nature is to be 
made after an investigation of the history of each case, which often 
includes a record of contact with cadavers or persons capable of com- 
municating the disorder. The epitheliomatous warty growths on the 
dorsum of the hands of elderly persons are not to be confounded 
with tuberculous lesions. In the former there is commonly a history 
of longer existence of the wart, and no record of suspicious con- 
tacts ; while a careful search will usually determine epitheliomatous 
metamorphoses over the cheeks or temples of the elderly man or 
woman with epitheliomatous warts on the hands. In the latter, too, 
the facial lesions are usually multiple, fatty-looking scales, thicker in 
one part than another, resembling those of a severe seborrhea, but 
which are removed with difficulty, and which then leave a bleeding 
surface beneath. 

In the orificial cases it must be remembered that tuberculosis of 
the viscera is a probable coincident disease. The microscope usually 
is needed for an exact diagnosis. 

In obscure cases of any variety Koch's old tuberculin in doses rang- 
ing from one quarter of a milligram (.00025) to three milligrams 
(.003) may be used for purposes of diagnosis and is valuable. Both 
a local and general reaction usually follows in positive cases. For 
details see chapter on General Diagnosis. 

Treatment of Tuberculosis Cutis. — The internal treatment of 
tuberculosis cutis is practically that indicated by the condition of the 
patient, inasmuch as no medicament is known to be capable, after 
ingestion of relieving the victim of his local ailments. Of the articles 
in this category none will be more often indicated than cod-liver oil, 
the chalybeates, creosote, the bitters, the preparations of iodine, and 
possibly phosphorus. Iodoform and potassium iodide have been 
recommended by Ueisser, who employs the former in pills, each con- 
taining -| grain (0.038). Guaiacol and creosote carbonate, either of 
them, in 5 grain (0.33) capsules, have been used with varying degrees 
of success. In London thyroid-extract has been given for cases of 
extensive tubercular disease of the skin with seeming benefit, though 
no complete cures are reported. The hypophosphites are useful in 



TUBEBCULOSIS CUTIS. 623 

many cases. Arsenic and mercury are powerless to prevent extension 
of the disease. It is needless to add that a diet of the most generous 
character is to be supplied, and the rules of hygiene enforced. 

Patients of the tuberculous class manifest in the highest degree 
the beneficial effects of a change of residence and climate — to the sea- 
shore or mountains from the interior valleys or plateau-lands ; often 
the reverse for those who reside by the sea or in mountainous coun- 
tries. It is the change which seems to produce the greatest benefit. 
An abundance of pure air and a life permitting out-of-door exercise 
are of the highest importance. The thermal and other springs of 
several countries furnish resorts where the benefit received is propor- 
tioned to the salubrity of the climate rather than to the special advan- 
tages of the waters furnished. Unfortunately, a large number of the 
patients affected with lupus and scrofuloderma are impoverished in- 
mates of public charities or applicants to dispensaries, where these 
aids in the management of .their ailments cannot be utilized. 

The local treatment of lupus vulgaris should have in view the re- 
moval of the morbid growth as painlessly and with as little resulting 
disfigurement as possible. These ends may be attained by surgical 
measures and by chemical and other applications. 

The most satisfactory results in the treatment of lupus vulgaris 
are obtained with the Finsen light. Not only is the method successful 
in removing the disease in the large majority of the cases, but the scars 
produced are much less disfiguring than those left by other methods, 
except the results obtained sometimes by radiotherapy, or in some of 
the circumscribed areas treated by Lange's plastic method. 

Finsen and Forchhammer 1 have published the records of the first 
800 cases of lupus vulgaris treated in Finsen' s Lysinstitut in Copen- 
hagen. These 800 cases were treated between November, 1895, and 
November 1, 1901. On October 1, 1902, the status of the cases was 
as follows : 

Excluding 71 cases in which death, illness, or other causes pre- 
vented a continuance of the treatment, there remained 729 cases in 
which the treatment was tested properly. Of these, 40, or 6 per cent, 
of the total number, received little or no benefit. The remaining 
689 patients, or 94 per cent, of the whole, were either entirely cured 
or much benefited by the treatment. Fifty-six per cent, were healed 
entirely, 17 per cent, having been under observation for periods vary- 
ing from two to six years, without recurrence of the disease. Eighty- 
two per cent, of the entire number were either entirely healed or 
showed but slight traces of the disease. These results are far better 

1 Mittheilungen aus Finsen 's med. Lysinstitut, Nos. 5 and 6. German transla- 
tion, Jena, 1904. The report contains 226 pages of text and the photographs of 
48 patients before and after treatment. The tables are prepared with the greatest 
care and detail, the cases being subdivided into four grades of severity; four 
grades according to extent of surface involved; and further according to the dura- 
tion of the disease, age of the patient, and coincident involvement of mucous mem- 
branes. The numbers and dates of treatments, resulting reactions, periods of free- 
dom from disease, dates of recurrences, and subsequent treatments, all are recorded 
accurately and definitely for each case. 



624 NEW-GROWTHS. 

than those given by any other method of treatment, and are the more 
remarkable when the fact is considered that the Lysinstitnt at Copen- 
hagen attracted to it a large number of cases of from ten to fifty 
years' duration in which all other methods of treatment had failed. 
In common with all who have spent any time or done any work in 
the Institute we can testify personally to the true scientific spirit man- 
ifested by Finsen and his associates, and consequently to the accuracy 
and trustworthiness of his reports, which established beyond question 
the value of the light treatment in this disease. The statistics demon- 
strate the frequency with which the mucous membranes are affected. 
In 72 per cent, of the cases the mucous membranes, usually of the 
nose, were more or less involved. Recurrences are due chiefly to rein- 
fection of the skin from the mucous membranes, which in most situa- 
tions are not amenable to the treatment by light, but have to be con- 
trolled by other methods. Moreover, it is exceedingly difficult to 
determine when mucous membrane lesions have been eradicated 
completely. The fact cannot always be decided without prolonged 
observation. 

The reports on lupus vulgaris from the Finsen Institute alone are 
sufficiently convincing, but during the last few years many other ob- 
servers in Europe, among whom may be mentioned Sequeira, Morris, 
Leredde, Gastou, Stroebel, Lesser, and Schmidt, and a few in the 
United States, including ourselves, 1 have established the value of pho- 
totherapy not only in lupus vulgaris, but in other forms of cutaneous 
tuberculosis as well. 

The apparatus and general technique are described on pages 127- 
131. In lupus vulgaris, deep penetration of the light is desired; 
hence, sittings of an hour or more are necessary. An inflammation 
deeply situated in the skin follows and reaches its acme in from twen- 
ty-four to forty-eight hours. The entire surface then is covered with 
vesicles or with a single large bulla. As soon as the reaction has sub- 
sided, which usually follows in about ten days, the area is given an- 
other treatment, and the process repeated until lupous nodules no 
longer can be detected in the tissue. As it is impossible to decide just 
when the last trace of the disease has disappeared, patients should be 
instructed to return after a few months for subsequent examination. 
In extensive cases daily treatments may be required in order to keep 
all the surface involved constantly under the influence of the light. 
The number of treatments required for each area varies from one or 
two to six or more. 

Phototherapy is not so effective, however, and may fail entirely in 
cases in which the penetration of light is prevented by extensive pig- 
mentation, or in which perfect exsanguination of the tissue is impos- 
sible owing to the presence of thick or irregular scars, densely infil- 
trated or hypertrophic areas, or when the disease is so situated, as is 
usually the case in mucous membranes, as to be inaccessible to pres- 
sure and direct radiation. Crusts and other obstacles to the penetra- 
nce report by Montgomery, J. C. D., 1903, xxi., p. 529 (with bibliography). 



TUBERCULOSIS CUTIS. 625 

tion of light should be removed by the usual methods. In some in- 
stances pyrogallol and other remedies may be used to lay bare the 
deeper nodules before applying the light. The expense of photother- 
apy for small areas is no greater than that of other methods, the re- 
sults are achieved as rapidly, and the cosmetic effects are assured. 
In large areas on covered parts of the body and where the cosmetic 
effect is not important, the treatment may be reserved for such lesions 
as do not yield to more rapid and less expensive methods. 

The x-rays have been used in cutaneous tuberculosis by Schiff and 
Freund, Kummel, Hollond, Knox, Pusey, and a number of other 
observers, including ourselves. The method is better than photother- 
apy for the cases described above in which pigmentation or great 
thickening of tissue prevents penetration of light. The x-rays are 
capable of removing not only the lupous nodules, but also of greatly 
reducing and improving the thickened and disfiguring scars so often 
seen in the disease following its spontaneous disappearance or its 
removal by other methods of treatment. It is possible with the 
x-rays to produce as perfect cosmetic results as are obtained regular- 
ly with the Finsen light; but in some instances, and especially if 
during the course of treatment a severe dermatitis has been produced, 
the scars may be marked by distinct telangiectases and are not quite 
so perfect as those obtained in practically every instance by photother- 
apy. Moreover, to be effective, the x-rays in cutaneous tubercu- 
losis must be pushed to the point of producing a decided reaction 
which is more or less painful and may necessitate suspension of the 
treatment for weeks at a time. 

Radium has been employed in a few cases with results similar to 
those obtained by the x-rays. 1 It apparently had no advantages over 
the two preceding methods and its practical employment is prevented 
largely by the difficulty experienced in obtaining sufficient quantities 
of a definite radio-activity. 

The thorn treatment employed by IJnna gives excellent results. 
The thorns of the gooseberry bush are saturated in the German 
" liquor stibii compositus," and one or more thrust firmly and deeply 
into each lupous nodule which it has been determined to attack. The 
base of each thorn is then cut off with a pair of fine scissors and the 
patch covered with a zinc oxide plaster. When the thorns are cast 
off a simple granulating ulcer is left which in favorable cases heals 
without delay. 

The obvious objection to each of the methods detailed above lies 
in the fact that an enormous proportion of lupus-patients have nasal 
and oral symptoms which cannot be reached either by the rays of 
solar or electric light or by IJnna's thorns. The local treatment of 
these involved mucous membranes is a matter of great importance, 
and is described below. 

Hollander's hot-air treatment of lupus is accomplished by direct- 
ing upon the lupoid tissue through a metal tube of slender diameter 
1 For references see p. 131. 

40 



626 NEW-GROWTHS. 

a stream of air at a temperature of about 300° C. The result is for 
the most part a destructive cauterization requiring complete anaes- 
thesia. The resulting scars may be formidable. 

The surgical procedure most frequently employed is curetting with 
a sharp spoon. This, with all other bloody operations in lupus vul- 
garis labors under the disadvantage of the possibility that tubercle- 
bacilli may be disseminated by the traumatism. Competent authors 
are arrayed on both sides of this question. Small lupoid patches 
certainly may be spread after resorting to most of the surgical de- 
vices employed as remedial agents. The dermal curette is a sharp- 
edged spoon with or without a fenestrum in the bowl to permit the 
escape of debris. By it the lupous growth may be completely scraped 
away, and, if necessary, caustics subsequently applied. Fox and 
others substitute for the sharp spoon the dental burr or dental excava- 
tor, though the change is not always for the better. Morris's double 
parallel screw-excavator is an improvement on the common burr. 
Often it is well to supplement the action of the spoon or excavator 
with the flat electrode treatment of Jackson. Gartner and Lustgarten 
originally used as an electrode a flat silver plate attached to the nega- 
tive pole of the battery, the plate being set in a hard-rubber ring. A 
current of from five to eight milliamperes is employed. 

The ablation of the entire lupous patch by the modern methods 
of surgery, followed by skin-grafting with the Thiersch or Lang 
method, gives good results, though the lupous growths may return 
sooner or later in the new skin. The objections to this method are 
chiefly that it involves the production of a larger and more conspic- 
uous scar, since, as a rule, more tissue is removed by the knife than 
by the curette and its allies. In the Lang 1 method the excision is 
made to include both the sound peripheral integument and half of the 
subcutaneous fat-cushion beneath, the skin-grafts employed later dif- 
fering from the thin Thiersch sheets in that they include the derma 
with the epidermis as far as the panniculus adiposus. 

The local treatment of lupus vulgaris by the aid of parasiticides is 
based upon the infectious character of the disease ; and in many 
cases is successful. White, 2 with a view to its parasitic action, ap- 
plies to the lupous patches rags soaked in solutions of mercuric chlor- 
ide, 1 to 2 grains to the ounce (0.066-0.133 to 30.), and also applies 
ointments containing the same quantity of bichloride in the ounce of 
salve-basis. Favorable results have been also secured by freely paint- 
ing lupous ulcers with a solution of corrosive sublimate in tincture of 
benzoin of the strength named. Salicylic acid, 2 to 4 per cent, solu- 
tions in castor-oil, and in ointments ^ to 1 drachm to the ounce (2.-4. 
to 30.) ; sulphurous acid, or pyrogallol in ointments of 10 per cent. 
to 50 per cent, strength, spread on linen rags, covered with imper- 
meable tissue, and followed by the use of mercurial plaster and iodo- 
form, have all been successfully employed with the same object in 
view. 

1 Der Lupus und dessen operative Behandlung. Wien, 1898. 
3 Boston Med. and Surg. Jour., 1885, cxiii., p. 409. 



TUBERCULOSIS CUTIS. 627 

Decidedly inferior to these are the following methods, the first 
named, most popular in Germany; the second, in France; the third, 
to-day practically obsolete, and probably not to be revived : 

The Paquelin knife is extensively used in Vienna. The finer 
blades, especially manufactured for the purpose, are thrust, at a red 
heat, again and again through the lupous tissue until it is destroyed 
in its depth. Over the whole the larger blade is firmly passed and 
pressed, the blackish coal resulting being the best subsequent dressing 
after the serous exudation ceases. Erasion is also followed by the use 
of the galvano- or thermo-cautery. 

Multiple linear scarification, a modification of the Dubini-Volk- 
mann method, was once claimed to have changed the prognosis of the 
disease. It is doubtful whether anything is to be gained by either a 
preliminary freezing of the part or the use of cutting instruments 
with many blades. The incisions may be produced with a delicate 
bistoury held in the fingers like a pen. They should be in parallel 
lines, closely set together, and crossed; should extend completely 
through the depth of the lupous growth; and this is determinable 
after some practice by the cessation of the creaking resistance which 
the blade fails to discover in normal tissue. Further, these incisions 
should extend laterally beyond the borders of the lupous patch into 
the sound peripheral zone. The bleeding is trifling and readily 
arrested by firmly pressing small pieces of fine sponge, lint, or ab- 
sorbent cotton over the part. The edges of the incision unite either 
by granulation or by first intention ; and in both cases seem to serve 
as starting-points of the reparative process, the material for which, as 
already pointed out, seems to be supplied from the lupous nests 
themselves. Subsequent operations, when needed, require a previous, 
freezing of the affected surface. In France and in some portions of 
the British Empire this method is still popular. 

Treatment by chemical cauterization alone is obsolete. The var- 
ious acids and alkalies, particularly potassium hydroxide and lactic 
acid, Cosme's paste, silver nitrate, arsenical, mercurial, and zinc 
compounds, and sodium ethylate have all been employed thus, and 
in suitably selected cases have been in the past productive of fairly 
satisfactory results. 

• With or without surgical interference, local applications may be 
employed, such as oily and fatty substances for the softening of 
crusts ; stimulating dressings of tar, iodated glycerin, thymol, guaiacol 
(Funk), ichthyol, carbolized glycerin, iodized phenol, fluorine (Phil- 
lipson), naphthol, chrysarobin, and iodoform; as also the carbolated 
unguents appropriate for the reparative phases of the ulcer left after 
the destruction of the lupous growth. 

ITnna advocates the topical application of 2 parts of beech-tar 
creosote to 1 part of salicylic acid, the latter for its marked effect 
upon lupous tissue, and the former for what is supposed to be its 
anodyne effect in obtunding the pain produced by the action of the 
acid on the surface. That this explanation of the effect of the com- 



628 NEW-GROWTHS. 

bination is not wholly correct is shown by the well-known fact that 
creosote alone is capable of producing' a curative effect upon lupous 
tissue. In a former edition of this work, issued before the date of 
Unna's experiments, creosote was set down as the dernier ressort of 
the physician in the topical management of lupus vulgaris. It can be 
used with the greatest advantage in severe cases not only by being 
brushed freely over the part, but also in the combinations suggested 
by Unna. It will be found that when employed alone it is far from 
having at first the local effect of a " morphine of the skin," being pro- 
ductive, where no cocaine has been previously employed, of exquisite 
pain, which, however, is usually short lived. It should be applied 
only with the greatest caution by the practitioner's own hands, its 
effects watched and, if need be, counteracted, as in the local em- 
ployment of potassium hydroxide. Trikresol operates in a similar 
manner. 

The application of fuchsin in 1 or 2 per cent, alcoholic solutions 
painted over the part, which has been previously scarified, is advo- 
cated by Fox and others. We have employed pyoktanin-blue in some 
cases with satisfactory results. 

In some of the German hospitals the new tuberculin-R, Koch's 
lymph, is injected, and it is claimed, with a larger success than fol- 
lows the older methods. It has not been unattended with danger 
and fatal results have in a few instances been recorded after its in- 
jection. In other cases general tuberculosis has been induced; while 
in yet others the degree of improvement following its employment has 
been inferior to that more readily reached by other therapeutic meas- 
ures. The dose is %oo to 1 milligramme, the strength being very 
gradually increased from the smaller to the largest amount named. 

The injection of calomel into the lupous patch has been followed 
by good results in the hands of Da Costa, Brouse, and Tschlenow. 

The treatment of verruca necrogenica and other verrucous tuber- 
culoses of the skin is practically that of lupus vulgaris. The curette 
may be followed by one of the caustics advocated above, preferably 
by pyrogallol, or a combination of salicylic acid and creosote. As a 
rule, mercurial lotions and salves are not well adapted to penetration 
of the warty or corneous envelope of the growth. 

The orificial lesions of tuberculosis cutis may, however, be well 
treated by these lotions, especially one in which ^ to 2 per cent, of 
mercuric chloride is dissolved in compound tincture of benzoin or 
tolu. 

Veiel applies in all the cutaneous tuberculoses pyrogallol-vaselin 
in the strength of 10 per cent., spread upon lint for three or four 
days. One part to twenty of salicylic acid may often be advantag- 
eously added. 

The local lesions of scrofuloderma may require the use of hot 
borated lotions applied temporarily, or kept permanently in contact 
on compresses covered by impermeable tissue. The results of sur- 
gical ablation of enlarged lymphatic glands, broken down or. threaten- 



ERYTHEMA INDUBATUM. 629 

ing scrofulous " gummata," and the complete disinfection and aseptic 
treatment to the point of cicatrization of the resulting wounds, fur- 
nish proofs of the progress of modern surgery. 

Prognosis. — The prognosis of tuberculosis of the skin in all its 
manifestations is in the highest degree variable. Many patients af- 
fected with lupus vulgaris even after the production of the severest 
grade of deformity, recover and without further local manifesta- 
tions gain a degree of facial comeliness that is marvellous. The 
scrofulodermata in the same way are remarkably improved, in the 
majority of all cases, by skilful medical and surgical management. 
In other cases systemic tuberculosis develops after even a single 
tuberculous infection, and grave results may occur either early in 
life or after years of tuberculous involvement of the skin and other 
organs. Other things equal, the prognosis in tuberculosis of the 
skin, as compared with that of other organs, is relatively favorable, 
due to the sparsity of tubercle-bacilli in most cutaneous lesions, the 
skin being exposed too largely to external influences to form a good 
field for development of new colonies of bacilli. Any form of tuber- 
culosis of the skin, however, may result in systemic infection and 
death. 

Erythema Induratum. 
(Eeytheme Indttke des Sckoeuleux, Bazin.) 

Erythema induratum is a chronic recurring disorder, usually in- 
volving the skin of the legs of young individuals, characterized by 
deeply situated nodosities and ulcerations. 

Symptoms. — The beginning of the disorder is marked by one or 
several deep-seated nodosities located in the hypoderm, which gradu- 
ally extend to the surface and undergo necrosis, producing ulceration, 
or after absorption, atrophy. They occur in successive crops, and 
may continue for years. They are usually bluish-red in color, though 
they may be a vivid red. They are painless as a rule, though pain 
may ensue after ulceration has occurred. The disease commonly 
attacks the calves of the legs of girls from fourteen to twenty years 
of age. Crocker has seen it in a woman of over fifty, but she had 
suffered with the disease earlier in life. It also has been observed 
but not often in boys and men. The front of the leg may be in- 
volved occasionally, and also the thigh and even the upper extremities 
(Crocker and Galloway). The nodules are hard, and can often 
be felt by palpation when not visible. They vary in diameter from 
one-half to one inch or more. Node-like patches may also be present. 
The lesions are symmetrical and may be few; but in time a number 
develop. The ulcers are irregular, ill-conditioned, with puriform 
contents, and tend to heal slowly, leaving scars. At a given time 
there may be present nodules, ulcers, atrophic areas, and scars, some 
of these being relics of former attacks. The disease occurs, as a rule, 
in public practice and is comparatively rare. It has been observed 
in connection with tuberculides of the folliclis type, and also in pa- 
tients having tuberculosis elsewhere than in the skin. 1 
1 Crocker, Diseases of the Skin, 3d ed., p. 812. 



630 NEW-GROWTHS. 

It is probable that, in the past, two diseases have been described 
under this heading: first, as described above, that which is the type 
and is probably tuberculous ; the other an ulcerative process due to 
vascular disturbances (Galloway, 1 Whitfield 2 ), this latter often occur- 
ring at a more advanced age, being more painful and more amenable 
to treatment. 

Etiology. — The affection occurs most frequently in the winter, 
and much more commonly in the female sex in the second decade of 
life. Washerwomen and shop-girls who stand much are liable to it. 
Its subjects often have a weak peripheral circulation, evidenced by 
cold blue hands or a chilblain tendency. The tubercle-bacillus, in 
the light of recent study, plays an important role in the type cases. 

Pathology. — From the studies of Fox, 3 Thibierge, 4 Mantegazza, 5 
and others, the tuberculous nature of the disease seems well demon- 
strated, although inoculation experiments are usually negative and 
the presence of Bacillus tuberculosis difficult to demonstrate. A 
granuloma with giant- and plasma-cells common to tuberculosis has 
been demonstrated repeatedly. Successful inoculations into guinea- 
pigs have been made by Fox and Eyre, Thibierge, and Ravant, and 
evidence is constantly accumulating which adds strength to the theory 
of its production by Bacillus tuberculosis. 

Diagnosis. — Erythema nodosum and syphilis are the two diseases 
most likely to cause confusion in diagnosis. From the former, ery- 
thema induratum is distinguished by its chronic course, its tendency 
to ulceration, the absence as a rule of pain, lack of fever, and other 
constitutional symptoms, the presence of scars, and its frequent asso- 
ciation with other evidences of tuberculosis. From the gummatous 
syphiloderm it is differentiated by the symmetry of the lesions, and 
absence of other evidences of syphilis ; finally, it is not benefited by 
specific treatment. 

Treatment. — General tonic treatment indicated in tuberculosis 
should be used in most cases. Rest in bed with elevation of the limbs 
is recommended. Before ulceration, bandaging should be practiced, 
and local antiseptic dressings after this last has occurred. 

DERMATOSES PROBABLY DUE TO THE TOXINES OF THE 
BACILLUS TUBERCULOSIS. 

Lichen Scrofulosorum. 

(Lichen Sceofulosus.) 

This eruption, first described by Hebra, 6 is characterized by its 
chronicity, and the occurrence chiefly upon the trunk, back, belly, 

1 B. J. D., 1899, xi., p. 206, and 1902, xiv., p. 199. 

2 Ibid., 1901, xiii., p. 386. 

3 Ibid., 1900, xii., p. 383 (Eeport on the Tuberculides, presented to the Fourth 
International Congress of Dermatology and Syphilis). 

4 Annales, 1889, s iii., x., p. 513. 

5 Ibid., 1901, s. iv., ii., p. 498 (abstr. in B. J. D., 1901, xiii., p. 438). 

6 See his remarks before the German Surgical Society, XIV. Congress. 



TUBERCULOSIS CUTIS. 631 

and thighs, of millet-seed- to pinhe ad-sized, firm, flat, light- to livid- 
red, and grouped papules. These are occasionally surmounted at the 
apex by a minute scale, rarely by an equally small pustule. The 
lesions are at the onset isolated ; later they tend to arrange themselves 
in coin-sized patches ; when evolution is accomplished they are closely 
set together, the surface of the skin being then of a dirty reddish- 
brown color, and covered with thin scales, which are readily detached. 
Often a crescentic outline can be determined in a group of aggregated 
lesions. y 

The course of the eruption is slow ; often the cutaneous symptoms 
persist for months without apparent change, awakening little or no 
pruritus, and are followed by involution, accompanied by slight des- 
quamation and no cicatrices. There may be recurrence. 

Etiology and Pathology. — In 99 per cent, of all cases observed 
in Austria there was concomitance of the general symptoms of struma 
named above (submaxillary, cervical, and axillary adenopathy, peri- 
ostitis, ulcerative dermatitis, etc.), with frequent complications, such 
as eczema of the scrotum. The disease was encountered in young 
tuberculous subjects between the periods of infancy and puberty, 
rarely after the twentieth year. Crocker 1 has noted its frequent oc- 
currence in children in whom he suspected tubercular pleurisy. 
Jadassohn 2 believes that it is a disease of the tuberculous, and not of 
the cachectic generally, and obtained typical reactions in fourteen 
of sixteen cases injected with tuberculin. He has seen the disease 
disappear after these injections. As to the question of its toxic or 
bacillary origin, opinion is still divided. In favor of the former 
theory, Schweninger and Buzzi, 3 Fox, 4 Klingmuller 5 and others 
have seen a disease apparently identical with it produced by tubercu- 
lin injections. It has been suggested that the injections may have 
stimulated a latent tuberculosis into activity, but in the histological 
study of a case thus produced Porges 6 found merely changes of an 
inflammatory character, with no evidence of a tubercular structure. 
In a case of lichen scrofulosorum in a negro child, Gilchrist 7 found a 
granuloma deeply situated, while the folliculitis which produced the 
clinical symptoms was more superficial. 

According to Kaposi, the disease consists in an exudative infiltra- 
tion of the pilo-sebaceous follicles and the perifollicular tissue. Each 
papule represents, therefore, the orifice of a follicle, with an infil- 

1 Diseases of the Skin, 3d ed., p. 448. 

2 Trans. Internat. Cong. Derm, and Syph., London, 1896, p. 425. 

3 Quoted by Brocq, Twentieth Century Medicine, vol. iv., p. 359. 
4 Arehiv, 1903, lxvi., p. 401. 

5 V. Klingmuller, Archiv, 1904, lxix., p. 167. The author gives a resume of his 
work and observations at the clinic of Professor Neisser and in seventeen cases 
of Lichen scrofulosorum his findings relative to tubercle bacilli were negative 
and animal experiments also failed. In a small part of the cases a tuberculous 
structure was present, but in the major part no suggestion of tuberculosis was 
noted. The result of this work strongly suggests the toxic rather than the local 
bacillary origin of the disease. 

6 B. J. D., 1900, xii., p. 384. 

7 Johns Hopkins Hosp. Bull., 1899, x., p. 84. 



632 NEW-GEOWTHS. 

trated perifollicular annex ; and its apical scale or pustule is formed 
of a mass of epithelial debris or an inflammatory exudate. Porges 
found areas of tubercular foci composed of round, epithelioid, and 
giant-cells in the corium. The vessels showed perivascular inflamma- 
tion, with cellular infiltration about the sweat-ducts. Jacobi, 1 Wolff, 2 
and Pellizarri 3 have been successful in finding the bacillus in the 
lesions or in producing inoculation tuberculosis in guinea-pigs. 

Diagnosis. — The disease is differentiated readily from papular 
eczema by the absence of itching. From the miliary papular syphilo- 
derm it differs in that the lesions of the latter, even though grouped, 
are always individually distinct. The general symptoms, moreover, 
are strikingly different in the two diseases. Lichen scrofulosorum 
should not be confounded with lichen planus or lichen ruber. Lichen 
pilaris, however, in a young and lymphatic patient might readily be 
mistaken for the disease in question. 

Treatment. — Entreated, the malady produces but little incon- 
venience, and, moreover, yields readily to therapy. Hebra advised 
cod-liver oil internally and externally. Crocker advises liquor plumbi 
subacetatis, grains 15 (1.), thymol, grains 5 (0.33), to vaseline, 1 
ounce (30.), to be applied externally, with the administration of cod- 
liver oil internally. 

Prognosis.- — The prognosis is favorable. 

TUBERCULIDES (DARIER). 

(Toxituberculibes [Hallopeau], Paratuberculoses [Johnston].) 

Under the title Tuberculides Darier 4 classed a number of cuta- 
neous affections which appeared to have many characteristics in com- 
mon. These diseases, or, rather, cutaneous manifestations of disease, 
have as a rule been observed in individuals the subjects of tubercu- 
losis in other organs than the skin, or who have hereditary tubercu- 
lous tendencies. Hallopeau and others have suggested that they are 
due not to the local action of bacillus tuberculosis, but to the toxines 
floating in the circulation from a distant focus. Fox 5 says that if 
they are due to the local action of Koch's bacilli, they must be few in 
number, of little virulence, and readily destroyed. Darier included 
in this category acne cachecticorum or scrofulosorum, disseminated 
or agglomerated folliculitis, acnitis, folliclis, hydrosadenitis destruens 
or suppurativa, granuloma innominatum, disseminated erythematous 
lupus (Boeck), etc. Fox, in his report on the tuberculides to the 
International Congress in Paris, in 1900, included among others in 
this list acne varioliformis, necrotizing chilblains, lichen scrofulo- 
sorum, and erythema induratum scrofulosorum (Bazin). The dis- 

i Verhandl. der Deutsch. derm. Gesell., III. Cong., 1891, p. 69. 

2 Ibid., VI. Cong., 1899, p. 486. 

3 Pellizarri, Trans. Internat. Cong. Derm, and Syph., London, 1896, p. 425. 
* Annales, 1896, s. iii., vii., p. 1431 (tuberculides). 

5 B. J. D., 1900, xii., p. 383 (Eeport on the Tuberculides, presented to the 
Fourth International Congress of Dermatology and Syphilis). 



TUBERCULIDES. 



633 



order last named is here considered as a manifestation of tuberculosis 
of the skin. Evidence is accumulating rapidly which tends to con- 
firm its position in the tuberculous column. According to Fox, " the 
essential lesion of the group of tuberculides is a small, extremely indo- 
lent granuloma, tending to undergo central softening and necrosis, 
and thus leaving scars. They are bilateral and symmetrical. The 
great clinical variation depends upon the depth at which the derma is 
affected, the implication or freedom of the glandular apparatus, the 
bulk of the granuloma, the distribution and number of the lesions, 
and the absence or presence of pustulation or necrosis." The sub- 
jects of these disorders often have a feeble peripheral circulation and 
are usually not robust. Two or more of these various lesions have 
frequently been noted in the same patient : for instance, lesions of the 
folliclis type on the upper, with erythema induratum on the lower 
extremities, or acneiform lesions with lichen scrofulosorum. A pa- 
tient whose case was reported by Johnston 1 had lesions on the arms 
which Johnston termed "necrotic granuloma," and others on the limbs 
which he termed " indurated erythema." Darier reported a case in 
which tuberculosis was present in the lungs and elsewhere, with tuber- 
culides of the type of acne cachecticorum on the body, folliclis on the 
knees and extremities, and a tuberculous gumma on the leg. Little 2 



Fig. 116. 




Generalized tuberculide 



all papular and verrucous lesions. 



showed a case at the London Dermatological Society with acneiform 
and gummatous tuberculous lesions present at the same time. Fox 
notes that large gumma-like lesions often are associated with acnei- 
form symptoms elsewhere. 



1 Phila. Med. Jour., 1899, iii. 
2 B. J. D., 1902, xiv., p. 352. 



634 NEW-GROWTHS. 

Symptoms. — These vary, as described above, according to the type 
of lesions present. In general, the disorders are chronic, the lesions 
deep-seated, beginning usually in the hypoderm or corium, extending 
into and involving the surface ; they are at first colorless, later bluish- 
or brownish-red or lighter in shade. They may suppurate, forming 
a pustule in the centre of the lesion. The latter dries into a de- 
pressed crust, which, when shed, leaves a small cicatrix ; or ulceration 
may occur, leaving a small depressed scar; or the lesion, nodule, or 
papule may be absorbed, leaving some atrophy with pigmentation. 
The lesions often are grouped and appear in successive series. Dif- 
ferent types show a predilection for different parts of the cutaneous 
surface. For example, lesions of the acnitis type select the face ; those 
of the folliclis type as a rule select the extremities. The lesions are 
generally painless and do not itch, and there may be a large number 
or only a few exhibited. 

Acnitis Type. — This variety Crocker 1 describes under the title 
"Acne Agminata." Here the lesions select chiefly the face. They 
occur in distinct groups in different regions, especially upon the 
cheeks below the eyes, the upper lip, the chin, and the forehead. 
The lesions are usually brownish-red in color, though many appear 
semitranslucent and almost colorless. They vary in size from that 
of a pinhead to that of a split pea, are firm to the touch, and occa- 
sionally the small papules or nodules are capped with a vesicle or 
pustule. The lesions are prone to remain for a considerable time, 
then undergo involution, leaving a small pigmented scar, which 
gradually becomes less conspicuous. In some cases involution occurs 
rapidly when once initiated. 

Folliclis Type. — In this variety the favorite sites are on the hands, 
forearms, feet, and legs, though the face may be attacked. The 
trunk seldom is affected. Here the lesions pursue a more rapid 
course, commonly completing their cycle in four to six weeks. They 
usually are noted first as red spots, which later develop into vesicle- 
or pustule-capped papules or nodules. They are firm to the touch 
and painless. The pustules dry into crusts, which reveal on exfolia- 
tion small cicatrices. While the lesions are usually discrete, patches 
may occur. The disease is chronic in its course. Barthelemy 2 re- 
ports a case lasting ten years, which had exacerbations, the patient 
never being entirely free. In the case of a patient recently examined 
by us the affection had lasted four years and appeared worse in the 
early autumn. This case illustrated the fact pointed out by Crocker, 
that the lesions on the fingers are more indolent and firm, and appar- 
ently have hard centres surrounded by a rim of pus. The disease 
occurs as a rule in persons having tuberculosis or with tuberculous 
antecedents. 

Etiology. — In a large number of patients presenting these lesions, 
some form of tuberculosis is present. Sometimes only an hereditary 

1 Diseases of the Skin, 3d ed., p. 1164. 

2 Quoted by Crocker. Diseases of the Skin, 3d ed., p. 1169. 



TUBEBCULIDES. 635 

tendency is manifest. Again, absolutely no evidence of tuberculosis 
can be demonstrated. While the disease may occur at any period of 
life, the most common age is, according to Fox, between twenty and 
forty years. Recently the tuberculides have been noted often in chil- 
dren. Morris 1 has observed that measles is a frequent forerunner of 
the disease. The patients are prone to have a weak peripheral circu- 
lation. Both sexes are attacked. 

Pathology. — The symmetry of the lesions and the early involve- 
ment of the bloodvessels point to some irritant brought to the cutan- 
eous surface through the general circulation. In different cases dif- 
ferent anatomical structures are affected more or less severely, which 
naturally alters the histological picture and has in consequence led 
to confusion in nomenclature. The relationship of the tuberculides 
to tuberculosis generally is conceded, but opinion is divided as to the 
exact nature of . this relationship. Histologically, a tuberculous 
architecture has been demonstrated clearly a number of times by dif- 
ferent observers. Many cases, however, merely show the changes 
incident to a simple inflammation. Inoculation experiments have, 
on the whole, been negative, and the presence of Bacillus tuberculosis 
in the lesions has rarely been demonstrated. The vascular changes 
in these conditions are evidenced by an endophlebitis, which often 
appears as the earliest phenomenon. Giant-cells and a tuberculous 
architecture have been demonstrated in different members of this 
group by Galloway, 2 MacLeod, 3 Darier, Leredde, 4 Bureau, 5 Little 6 
and others. Pollitzer, 7 Fordyce, 8 Unna, 9 Dubreuilh, 10 and others 
have noted special involvement of the coil-glands in some cases, but 
even these Leredde and Bureau consider secondary to a granuloma of 
tuberculous origin. In a histological study of two cases, one the 
acneiform type, the other the so-called scrofulous gummata, MacLeod 
and Ormsby found in both cases giant-cells and a typical tuberculous 
structure, with two tubercle-bacilli in the latter. 

Treatment. — The treatment of the general health is important in a 
majority of these cases. The hygienic surroundings should properly 
be regulated. Fresh air, sunshine, and good food are of prime im- 
portance. Cod-liver oil, iron, and other tonics, according to the 
special indications, should be used. In the folliclis type Crocker 
advises thiol, grains 5 (0.33) three times daily, with applications 
of 10 per cent, vasogen iodin. Antiseptic washes, such as boric-acid 
solution or bichloride of mercury (1 : 5000), may be necessary. Ex- 
cision may at times be employed. Mercurial plaster or an ointment 

i Diseases of the Skin, 1903, p. 422. 

2 B. J. D., 1901, xiii., p. 17. 

3 Ibid., 1901, xiii., p. 367 (report on the Histopathology of Two Cases of Cu- 
taneous Tuberculides, in one of which tubercle-bacilli were found). 

* Quoted by Crocker, Diseases of the Skin, 3d ed., p. 1167. 

5 Ibid., p. 1169. 

6 B. J. D., 1901, xiii., p. 185. 

7 Quoted by Unna, Histopathology, p. 399. 

8 J. C. D., 1891, ix., p. 128. 

9 Histopathology, p. 399. 

10 Arch, de Med.exper., et d'Anat. path., 1893, s. 1, v., p. 63. 



63() NEW-GEOWTHS. 

containing ammoniated mercury (1:30) may be applied. Radio- 
therapy has been of distinct value in several cases treated by us. 

" Tuberculous Eczema " (Unna) is merely an exudative affection, 
which may be recognized in proximity to the scrofulodermata, a proc- 
ess awakened by the irritative effects of the latter; or the disease oc- 
curs as do other affections, in scrofulous patients. 

Melanoderma of the Scrofulous (Pigmentary Tuberculide). — In 
some of the subjects of scrofula and tuberculosis a hyperpigmenta- 
tion of the skin has been produced strongly resembling the pigmen- 
tary syphilide. The coloration is in varying shades of brown, and 
forms a reticulated staining of the regions about the face and neck, 
though other parts may be involved. Between the pigmented spots 
lighter points and dots of a less deeply stained integument are com- 
monly visible. The well-known influence of tuberculosis of the 
adrenals in the production of pigment-changes in the skin lends color 
to the belief that some of these cases are due to the toxines of a tuber- 
culosis of non-integumentary tissue. Similar pigment-changes in the 
skin have been determined to be the result of paludism, carcinoma, 
syphilis, and other disorders; and it is reasonable to conclude that 
the changes here set down in some instances at least are the product 
of tuberculous toxines. 

Lupus Erythematosus (consult the following chapter) is by some 
authors classed with the disorders grouped under the title of tubercu- 
losis cutis or as a paratuberculosis. The evidence that it is itself a 
cutaneous tuberculosis is wanting. That, however, it is in some cases 
a dermatosis of tuberculous subjects cannot be questioned. 

LUPUS ERYTHEMATOSUS. 

(Lat., lupus, a wolf.) 

(Lupus Sebaceus, Lupus Superficialis, " Scrofulous Ring- 
worm," Seborrhea Congestiva, Lupus Erythematodes, 
Lupus Non-exedens, Ulerythema Centrifugum. Fr., 
Scrofulide Erythemateuse, Erytheme Centrifuge.) 

This disease was first described by Biett under the title Erytheme 
Centrifuge. Hebra, in 1845, described it among the seborrheas, as 
Seborrhcea Congestiva. Its present title was given by Cazenave in 
1850. 

Symptoms. — The disease is first exhibited in one or several rape- 
seed- to bean-sized, slightly elevated, reddish macules which do not 
entirely fade under pressure and are covered with a grayish or yellow- 
ish and sometimes slightly greasy, adherent scale. 

In the ordinary Discoid form of the disease the primary lesion 
described above enlarges its periphery in the course of months or 
years by a slowly continuous development. It may thus gain the 
size of a small coin or a large saucer. The disks or patches are well 



LUPUS ERYTHEMATOSUS. 



637 



defined in outline, of a color varying with the complexion of the pa- 
tient and with the acuteness or type of the disease, from a rosy- 
pinkish to a deep-purplish hue. The shape is usually circular, oval, 
or in figures representing combinations of these outlines, but it may 
be irregular from the junction of two or more progressing patches. 
Its border is red, firm to the touch, and distinctly elevated, and not 
infrequently exhibits comedones or light adherent scales. The centre 
is depressed, paler in color, and shows either adherent yellowish-gray 

Fig. 117. 




Lupus erythematosus of the face. 

scales or a glistening unbroken epidermis. Close examination will 
disclose in most cases dilated follicular openings which may be 
plugged with dried sebaceous matter or horny epithelium. The 
scales vary in color, being at times of a clear white or whitish yellow, 
and again often from concurrence of comedones of a reddish or 
brownish tint. They are usually scanty and adherent, but may be 
abundant, and occasionally can be seen firmly fastened to the orifice 
of the excretory duct of a sebaceous gland by means of a horny pro- 
jection from the under surface. In some cases the erythematous red- 
ness, in others the crusted surface of the disk, is the most pronounced 
feature. In the latter there are seen at times patches exhibiting al- 
most a pure type of seborrhcea faciei. 

It may spread symmetrically over the nose and cheeks in a form 
that has been likened by Hebra to the open wings of a butterfly. The 
disease is seen most frequently on the different parts of the face, ears 



638 



XEW-GEOJVTHS. 



and scalp, and may occur on any part of the body. On the scalp 
small irregular patches or larger areas may appear. There is usually 
more 'infiltration, and more pronounced scar formation, but less color 
and less elevation of the border than in lesions of the face. The 
dilated follicles and comedones are often pronounced. The alopecia 
which results is permanent. On the hands 1 and feet the disease may 

Fig. 118. 




Lupus erythematosus (seborrhceic type). 

occur in the usual form or as a persistent erythema with slight scaling, 
but it more commonly begins as a lupus pernio. The mucous mem- 
brane may be involved, presenting reddened plaques with minute ex- 
coriations, or be partially covered with a whitish exudate or with 
punctate scars. 

As the borders advance the centre not infrequently undergoes invo- 
lution, and may show typical scars even while the outer rim is actively 
progressing. When the disease undergoes general involution both 
the centre and the border gradually become paler in color and less 
elevated. Some of the patches resolve without leaving a trace of 
their existence, but in most instances typical scars are left. These are 
indelible and characteristic. They are generally uniform and super- 
ficial, can be pinched up readily between the thumb and finger, are of 
a dull whitish tint, and rendered punctate in a peculiar manner, sug- 

1 Cf. paper by me, with 35 tabulated cases in which the hands were affected 
(J. C. T>., 1884, ii., p. 321). 



LUPUS ERYTHEMATOSUS. 639 

gesting the action of the engraver's tool in what is known as the 
''stippling" process. They are never pigmented, puckered, radiate, 
stellate, corded, or deeply attached. Subjective sensations are usu- 
ally slight or absent, but some itching or burning may be present dur- 
ing periods of activity in the lesions. 

The disease is remarkably chronic in its course, lasting in cases for 
a quarter of a century or even longer, and throughout not interfering 
with the general health. So-called " galloping cases," usually with 
marked visceral complications, are described by French writers. 
Though the disease usually progresses by a very slow extension of 
the border, it may, after remaining comparatively stationary for 
months or years, rapidly advance for a short period and then again 
remain stationary. These periods of rapid progression usually follow 
or are accompanied by a peculiar type of acute dermatitis suggesting 
a mild form of erysipelas. 

Lupus Disseminatus. — The disease may occur in a diffuse form. 
As a rule, the lesions first appear on the face, but later they may de- 
velop on any part of the body, and often large surfaces are involved. 
The lesions are small, varying in size from that of a pinhead to that of 
a bean, and though usually presenting characteristics similar to the be- 
ginning patches of the more common type, they may assume atypical 
forms resembling the lesions of erythema multiforme, urticaria, 
syphilis, acute psoriasis, or pityriasis rosea. At times the subjective 
sensations are severe (itching, burning, heat, etc.), and the patches 
may even be the seat of vesicles, pustules, or bullae. This form of the 
disease is accompanied in most instances by such systemic disturbances 
(arthritic, gastro-intestinal, and febrile) as occur in erythema multi- 
forme. In rare instances there are changes suggesting erysipelas 
sometimes accompanied by typhoid and other malignant symptoms. 
This condition was designated by Kaposi as erysipelas perstans faciei, 
and he reported that in 50 per cent, of the cases death resulted. 

Unusual Types. — Fr., Ekytheme Centrifuge. — Among the un- 
usual types of the disease may be mentioned this acute form which 
has most of the characteristics of the described varieties, in which the 
symptoms are more acute and the vascular elements more marked. 
This condition may disappear, leaving the skin entirely normal, or it 
may be followed by the more common type of the disorder. The 
reddened plaque has been by several authors likened to the lesions of 
exudative erythema, being hot to the touch, tender, raised, and mani- 
festly centrifugal in its mode of extension. 

Telangiectatic. — This form is occasionally seen. Here points, 
spots, plaques, or large disks on the surface, chiefly of the face, usu- 
ally well defined, present a rosy-reddish, or deep-purplish color which 
disappears under pressure. When examined with care the color is 
seen to be due to dilatation of the cutaneous vessels. The surface may 
be either slightly (edematous, or infiltrated, and correspondingly ele- 
vated. There is an absence of scaling and of dilated follicles, but 
typical scars not infrequently follow the involution of this type of the 
disorder. 



640 NEW-GROWTHS. 

Lupus Pernio 1 is another unusual form in which the lesions are 
exhibited on the fingers and toes particularly but also on other parts 
of the hands and feet and on the pinna of the ear, beginning as a 
more or less persistenl erythema of the type of pernio (chilblain). 
Like the latter disease, this erythema may disappear and reappear 
with the seasons for several years, but eventually may persist and 
assume the discoid type. 

The Livedo Fokm. — A rare subvariety is recognized on the face, 
hands, and other regions where the symptoms present the character 
of local asphyxia. Here the influence of the trophic nerves, as in 
other conditions with similar symptoms, is distinct. The disease 
begins with the production of livid spots in the regions named, which 
persist for months or even years, and eventually degenerate at the 
centre, leaving a slough beneath which is an ulcer. In these cases, 
also, tuberculous complications may occur in the joints. 

Etiology. — The disease is more common in women than in men, 
two-thirds of the former to one of the latter, and usually appears 
first in the third decade of life, in this particular presenting a con- 
trast with lupus vulgaris. It may, however, first develop in child- 
hood, middle life, or old age. 

Lupus erythematosus may follow eczema seborrhoe'icum, acne, un- 
due exposure to sunlight, variola, erysipelas, vesication with cantha- 
rides, or traumatism from any cause. It may appear where the 
curette has been employed in a patient with a characteristic patch else- 
where on the face. It occasionally develops on portions of the face 
and hands that have been subject to recurrent attacks of pernio, and 
it is generally accepted that enfeebled circulation and local irritation 
are prominent causal factors. It occurs in conjunction with anaemia, 
chlorosis, and other disorders. In many patients careful investiga- 
tion fails to discover any other evidence of ill health. By an in- 
creasing number of writers the disease is considered a chronic in- 
flammation due to a toxic infection, the exact nature of which is not 
known. 2 Its association with erythema multiforme is frequently 
observed. 

The relation of lupus erythematosus to tuberculosis has been a 
much disputed question. The disease is described by some writers as 
a variety of lupus vulgaris, but the histopathology of the former dis- 
ease, the absence of tubercle-bacilli, and the negative results of many 
inoculation-experiments seem sufficient to disprove such relationship. 
The transitional forms occasionally reported usually prove to be mild 
and unusual types of lupus vulgaris. 

Although lupus erythematosus has none of the essential character- 
istics of a local tuberculosis, it occurs not infrequently as a derma- 

1 Cf. contribution to this subject by me, loc. cit. 

2 Galloway and MacLeod, B. J. D., 1903, xv., p. 81, believe that lupus erythe- 
matosus, like erythema multiforme, may be due to toxaemias arising from various 
causes. See same authors in ibid., 1908, xx., p. 65. Cf. also, Warde, B. J. D., 
1902, xiv., pp. 380 and 447, and 1903, xv., p. 161; F. v. Poor, Zeitsch., 1901, viii., 
p. 103; Sequeira and Belean, B. J. D., 1902, xiv., p. 367 (bibliography); Voirol, 
Inaug.-Dissert. Berne, 1903, reviewed in Monatsh., 1905, xl., p. 625. 



LUPUS ERYTHEMATOSUS. 641 

tosis of the tuberculous. Besnier was the first to call attention to 
the fact that lupus erythematosus is in many instances associated 
with general or local tuberculosis. Cases in which this association 
occurred have been reported by a number of observers. Boeck 1 re- 
cords forty-two cases of the common discoid type, in twenty-eight of 
which he found evidences of present or past tuberculosis. Roth 2 
collected records of two hundred and fifty cases of lupus erythema- 
tosus, in one hundred and eighty-five of which evidence of local or 
general tuberculosis could be obtained. 

Tuberculosis could thus be counted as an important factor in 
the etiology of lupus erythematosus, but that it is the sole cause or 
even an essential factor has not been demonstrated. It is associated 
more frequently with the disseminated than with the discoid forms 
of the disease. Pick, 3 after studying the effects of tuberculin in- 
jections in twenty-nine cases, concluded that lupus erythematosus dis- 
coides is not a manifestation of tuberculosis. Sequeira and Balean, 4 
after an investigation of seventy-one cases, agree with Pick regard- 
ing the discoid variety, but found tuberculosis frequently associated 
with the disseminated form. 5 They found albuminuria in one-half 
of the cases of this type. 6 The disease is seen frequently in individ- 
uals in whom there is no history or other evidence of tuberculosis in 
any form. 

Pathology. — Lupus erythematosus has been studied carefully by 
a number of observers, but unfortunately they do not agree either in 
their histological findings or in their conclusions based upon the latter. 
In general it may be said that the chief changes are found in the 
upper half or third of the corium in the form of a dense infiltration 
of small round cells of embryonic type, a small proportion of which 
is probably the result of proliferation of the fixed cells of the part. 
The infiltration varies greatly in extent and in density in different 
types of lesions, but is most pronounced along the course of the ves- 
sels. It is often found in slight degree in the deeper parts of the 
corium and subcutaneous tissue ; but it nowhere forms nodules as in 
lupus vulgaris ; there are no giant-cells ; and there is no degeneration 
of a mass of cells as in the latter disease. Individual cells here and 
there undergo a granular and fatty or colloid degeneration, disappear 
by absorption, and are replaced by new cells. The connective-tissue 
fibres are destroyed in the same way. Many of the vessels are seen 
to be greatly distended and choked with red blood-corpuscles, others 
show a proliferation of their walls and in some cases an obliterating 
endarteritis. Diffuse or localized hemorrhages are found in the up- 
per part of the cutis. The sebaceous glands are at first hypertro- 
phied, affected with hypersecretion, and become filled with cells and 
i Archiv, 1898, xlii., p. 71. 

2 Ibid., 1900, li., p. 3. 

3 Ibid., 1901, lviii., p. 358 (bibliography) . 

4 Loc eit. 

5 Cf. Civatte, Annales, 1907, s. iv., viii., p. 263, for an excellent resume of 
opinions as to the nature of lupus erythematosus. 

6 B. J. D., 1903, xv., p. 249. 
41 



642 NEW-GEOWTHS. 

abnormal sebaceous matter. Later both they and the ducts of the 
coil-glands may become infiltrated, undergo degeneration, and disap- 
pear, leaving the peculiarly punctate form of scar characteristic of 
the disease. 

The epidermal layers are involved secondarily. They become 
atrophied, and the interpapillary depressions of the rete as well as the 
papilla? are largely obliterated. 

Fordyce and Holder 1 investigated a number of cases of the dis- 
coid type and describe a peculiar blocking of the capillaries with blood 
cells which they believe to be the primary change. They divide the 
factors making up the histopathological complex into the round-cell 
infiltration, the peculiar degenerated condition of connective tissue, 
and the secondary atrophy. They find that the commonly described 
fatty and granular degeneration is not characteristic of the process. 
Schoonheid, 2 from a histological study of twelve cases, concluded 
that lupus erythematosus is a chronic inflammatory process, and 
describes a peculiar degeneration and destruction of the elastin, which 
he believes to be the immediate cause of the superficial scars. Warde 
regards the profound stasis in the lymph and blood channels as the 
most important feature in the histology of the disease. 3 Hollender 
considers the pathologic process to have its origin in the glands of 
the skin. 4 

Robinson, 5 after examining a number of cases and reviewing the 
published reports of others, states that the primary lesion, which 
may be seated in any part of the corium, is focal in character, and 
when fully developed constitutes a new-growth, which is reticular in 
structure and closely connected with the lymph-channels. He con- 
cludes that " lupus erythematosus is a chronic inflammatory disease of 
the cutis with special histological characters, as shown by the changes 
in the blood-vessels by reticular tissue, by the presence of mononu- 
clear and by the absence of polynuclear cells in the cell-infiltration; 
and that these changes must depend upon the presence of a poison 
generated in loco. In other words, lupus erythematosus is a local 
infective process — a granuloma." 

Diagnosis.— The facies of the patient with lupus erythematosus of 
that region is usually so characteristic that the disease is there recog- 
nized with ease. When the hand and other portions of the body are 
involved the diagnosis is somewhat less readily established. In the 
hand the disease has a predilection for the dorsum, and invades the 
palm usually only by extension to it from behind. 

From lupus vulgaris erythematous lupus may be recognized by its 
occurrence originally at a later period of life ; bf its greater tendency 
to symmetry ; and by the absence of nodules, ulceration, and extension 
to the deeper portions of the skin or underlying structures. Cases 

1 N. Y. Med. Kecord, 1900, lviii., p. 41. 

2 Archiv, 1900, liv., p. 163. 

3 B. J. D., 1902, xiv., p. 447. 

4 Berl. klin. Wochenschr., 1903, No. 30. 

5 Trans. Amer. Derm. Assoc, 1898, p. 70. 



LUPUS ERYTHEMATOSUS. 643 

undoubtedly occur in which the diagnosis is difficult, as in the type 
called by Leloir lupus vulgaris erythematoi'de. But as in all cases of 
lupus vulgaris typical nodules appear sooner or later, the diagnosis 
can eventually be established. 

In eczema there is usually some history of moisture ; in erythema- 
tous lupus, rarely. In eczema, also, the itching is a more persistent 
and distressing symptom; but the acuteness of even chronic eczema, 
as compared with lupus erythematosus, will suffice to distinguish the 
two diseases. From dermatitis seborrheica, however, the diagnosis 
may be difficult and may have to depend on a therapeutic test, the 
latter disease disappearing under appropriate treatment. Psoriasis 
is rarely, if ever, limited to a single patch on the face ; it is also char- 
acterized by more lustrous and more readily exfoliating scales. Its 
patches are, furthermore, uniformly well covered with scales, and are 
of equal flatness in all parts, while those of lupus erythematosus are 
irregularly squamous, the scales being often clustered at the orifices 
of the ducts of the sebaceous glands, while the rim of the patch is 
elevated and the centre depressed. From pernio the diagnosis some- 
times can be made only after determining whether the lesions disap- 
pear during the warm season, as in pernio, or persist, as in lupus 
erythematosus. 

In acne rosacea there are marked telangiectases and papulo-pus- 
tules or nodules which are not found in erythematous lupus. In 
tinea circinata there may be a clearing, but never a cicatriform centre 
of the circular disk. The circular serpiginous syphilodermata of the 
face occur usually with other manifestations of lues, are characterized 
by greater infiltration, a more rapidly progressing border formed by 
the coalescence of individual papules, or tubercles, and in most cases 
the syphilitic lesions exhibit distinct signs of ulceration. The not 
infrequent modification or masking of a patch of the disease by an 
acute or subacute dermatitis (often seborrheal in character) should 
be borne in mind. 

Treatment.- — The internal treatment of this affection is not highly 
satisfactory ; often none is indicated or required. The general health 
of the individual should be carefully investigated, and all defects 
remedied if possible. The administration of potassium iodide, mer- 
curic iodide, iodoform in 1 grain (0.06) doses ( Whitehouse) , starch 
iodide, arsenic, ammonium carbonate, ichthyol, sodium salicylate, 
and many other remedies have been advocated by different writers. 
It is doubtful if these articles ever do good unless indicated by the 
patient's general condition, while they often do much harm. The 
last three remedies on the list given above are said by F"ox, Unna, 
and others, to lessen the congestion of the face. When they do 
produce this effect it is possible that advantage may be derived 
from their use. Good effects have been reported following the use 
of large doses of quinine and of salicin. 

The number of remedies recommended for local use in lupus 
erythematosus is enormous. White, 1 in reviewing the subject, has 
1 J. C. T)., 1898, xvi., p. 457. 



644 NEW-GROWTHS. 

enumerated some fifty of those most promising, at the same time 
calling attention to the fact that lupus erythematosus is no exception 
to the rule that "the curability of a disease is in inverse ratio to the 
length of the list of the means recommended for its cure." He 
admits that our treatment of this disease is wholly empirical, and not 
very hopeful. Unna 1 attempts a rational form of treatment based on 
his conception of the etiology and pathology of the disease and of the 
action of certain remedies. While his scheme is based largely on 
theories that are not yet capable of demonstration, the details of his 
treatment are of practical value. He calls attention in particular 
to the fact that, while the epidermis is exceedingly dry and hyper- 
keratotic, the cutis is markedly oedematous and the seat of dilated 
lymph-spaces and channels, and emphasizes the dangers of stimulat- 
ing a dry indolent process into an active dermatitis. 2 

For convenience, the remedies used may be divided into three 
classes : the soothing and astringent, the stimulating, and the destruc- 
tive. The choice of remedies will depend largely upon the type of 
the disease and on the character of the individual skin. In the acute, 
inflammatory, or vascular type soothing remedies alone should be used 
and on a skin which reacts readily to stimulation stronger remedies 
are not allowable. !NY>r should it be forgotten that the indolent forms 
of the disease not infrequently under treatment become acutely in- 
flamed, and call for the temporary use of soothing measures. Inas- 
much as the affection is one the involution of which occasionally is ac- 
complished under the influence of mild topical applications, and is 
succeeded very rarely by grave sequels, the simpler measures should 
always be adopted first. In the way of soothing and astringent prep- 
arations, the lotions, powders, simple ointments, and pastes recom- 
mended for the treatment of acute eczema can be employed to advan- 
tage. The zinc oxide powders and lotions are especially to be com- 
mended, as are also the cold-cream salve, the Hebra, and the zinc 
oxide ointments. The paste containing equal parts of lanolin, vaselin, 
zinc oxide, and talcum makes an excellent base. Broeck's liniment 
(talci, amyl, aa 3ijss (10.) ; glycerin., §j (30.) ; aq. plumbi, §v 
(150.)) ; and Unna's "pulvis cuticolor" (zinc, oxid., boli rubrse, aa, 
2 ; boli alba?, magnes. carbonat., aa, 3 ; amyl. oryzae, 10) are valuable 
preparations in acute and irritable stages of the disease. 

Frequently much can be accomplished through protection and com- 
pression of the surface by the application of collodion, the glycogela- 
tins, or tragacanth- jelly. Unna recommends especially for irritable 
cases : 

]£ Ichthyol. (vel ichtbyol. sulfon.), 5ss; 21 

Collodii, 5v; 20 1 M. 

For more indolent cases : 

^ Saponis virid., 3ss-ij ; 2-41 

Collodii, 3v; 20 1 M. 

To the latter may be added 1 or 2 parts of salicylic acid. 

1 Ibid., p. 465. 2 Cf. Warde, B. J. D., 1902, xiv., p. 447. 



LUPUS ERYTHEMATOSUS. 645 

TInna recommends also gelanthum as a substitute for collodion in 
the above formulae, for though it does not produce as much compres- 
sion as the latter it is more convenient in that it may be washed off at 
any moment with warm water. A favorite formula with him is 
potass, hydrat., 1; gelanthum, 1000. 

For the purpose of producing more or less stimulation of the sur- 
face there may be added to the lotions, ointments, and pastes suggested 
above from 2 to 20 per cent, of sulphur, or from 1 to 5 per cent, of 
salicylic acid, white precipitate, resorcin, ichthyol, or tar. The mild 
salicylated soap plasters or the plaster-mulls containing the above 
remedies in small amounts, or a reduced mercurial plaster may be 
used where a moderate amount of stimulation is desired. Excel- 
lent results follow the use of green soap applied as a plaster or in the 
form of tincture. It not only cleanses the patches of the scales, but 
also stimulates the surface, often to the extent of inducing a repara- 
tive process. The patch may be briskly rubbed either with soap or 
tincture of soap in combination with hot water, after which a simple 
ointment or one containing a small amount of sulphur or other of the 
remedies suggested above may be applied. When decided irritation 
of the parts is produced, the soap should be discontinued and the hot 
water and ointment be employed alone for a time. A decidedly bene- 
ficial effect is noted occasionally after the topical application, for 
twenty minutes at a time, of very hot water alone. After drying, the 
surface should be dusted with a powder or covered with a simple oint- 
ment or paste. 

The following is a gentle stimulant : 

# Zinci sulphat \ aa 3 ss; aa 2| 
Potassse sulphurat., J 

Spts. vin. rectif., * 3ii.i ; 12| 

Aq. rosa>, i^jss; 105 1 M. 

Sig. To be diluted as required for external use. 

The following is a formula for a stronger lotion : 

# Chrysarobin., 3ijss; 10 1 
Acid, salicylici, 1 aa 3 aa 2 \ 
Calamima pulv., J 

JEtheris, f 3j ; 41 

Collodii flex., *3vj 20| M. 

Sig. To be applied with a brush. 

The non-vascularized, indolent varieties of erythematous lupus 
are often treated with very satisfactory results by the topical applica- 
tion of a saturated solution of pyoktanin-blue. This method has the 
great disadvantage of producing a deep bluish stain of the face, but 
the disfigurement is willingly tolerated for a brief period by patients 
who have long suffered from the facial unsightliness of the disease 
itself. The solution is thickly painted daily over the entire portion 
affected ; and the application usually may be made by an unskilled 



646 NEW-GBOWTES. 

hand. Xo pain is produced and no untoward effect of any kind has 
been noted. The applications have been repeated continuously for 
sixty days and more with excellent results. 

Hans Ilebra 1 applies several times daily alcohol on cotton pads. 
The evaporation of the spirit and abstraction of water produce the 
beneficial effect. 

A combined internal and external treatment has been devised 
by Hollander, 2 the medicaments used being quinine and tincture 
of iodine. His method is as follows: T 1 ^ grains (.50) of quinine 
or quinine sulphate are given three times a day ; after taking, each 
area of the disease is thoroughly painted with tincture of iodine. 
After five or six days a rest from treatment is taken until the scale 
from the application has peeled off. Several courses of treatment as 
above may be needed, though sometimes one suffices. Hollander 
regards his method as specific and of value in differential diagnosis. 
Excellent results have been reported by many observers. Before ap- 
plying the treatment the patient should be tested for any idiosyncrasy 
against quinine. 

Lupus erythematosus has been treated successfully with photo- 
therapy and with radiotherapy by a number of observers, including 
Finsen, Leredde and Pautrier, Gastou, Moris and Dore, Pusey, and 
ourselves. 3 After seven years experience with these methods we be- 
lieve they are of distinct value in selected cases. Radiotherapy gives 
prompt results especially in the seborrheic variety of the disease, but 
to produce permanent relief from the disease there is danger that tel- 
angiectasia may later supervene which mars the ultimate result. At 
present our method is to employ the treatment in moderation and 
if the disease is resistant, to resort to other means. The high fre- 
quency current has been used with success by a number of observers. 

In our experience, the lesions in which the vascular element pre- 
dominates or which are subacute in type do better with phototherapy 
than with x-rays. Lesions with marked infiltration and decided in- 
volvement of the glands and follicles resist the light treatment and 
improve more rapidly under rc-rays. 

Liquid air and carbon dioxide snow are now being employed 
with some success. Sufficient time has not yet elapsed to fully deter- 
mine their value, but recurrences are noted in cases where the result 
at first gave much promise. 

In exceedingly obstinate cases, those especially in which the ele- 
vated rim of the erythematous disk refuses to yield to the simple 
measures described, a solution of caustic potash in distilled water, 1 
part to 2 or 4, may be gently applied with a camel's-hair brush, and 
the alkali immediately neutralized by the addition of dilute muriatic 
acid as soon as the desired effect is produced. That effect, it must 
be remembered, is superficial cauterization only. When the sero- 
sanguineous exudation and reactive effects disappear the rim is seen 

1 Wien. med. Wchnschrift., 1899, xlix, p. 13. 

2 Berl. klin. Wochensch., 1902, July. 

3 J. 0. D., 1903, xxi., p. 529 (bibliography). 



SYPHILIS. 647 

to be flattened and to have lost in part its violaceous blush. After 
such severe application, which should never be trusted to the hand 
of one unskilled in its use, an anodyne cerate containing morphine or 
opium should be spread over the part. 

In indolent patches where decided stimulation or even a very 
superficial destruction of tissue is desired, mercurial plaster, the 
stronger salicylated soap-plasters, and plaster-mulls are to be recom- 
mended, or creosote, carbolic acid, chrysarobin, pyrogallol, salicylic 
acid, and pyrogallol (1 part of the first and 3 of the second to 40 parts 
of flexible collodion, Brocq), silver nitrate, lactic acid, or Fowler's 
solution may be used. Two drachms (8.) each of iodine and potas- 
sium iodide mixed with 4 drachms (16.) of glycerin; or equal parts 
of chloral, tincture of iodine, and carbolic acid, are recommended 
highly. These stronger remedies, however, are to be used with great 
caution and only in indolent cases, and then only after milder 
measures have failed to produce good results. 

In a few cases electrolysis has been of benefit. Erasion with a 
dermal curette, 1 as well as operation by multiple punctures or by 
linear scarifications, is of less value than in lupus vulgaris. Erasion 
has in some instances been followed by involution of the disease, but 
also, as a rule, by cicatrices that are no less disfiguring than the origi- 
nal disorder. 

Prognosis. — A favorable opinion with respect to the future of the 
disease never can be given safely, but with improved technique a 
large percentage of cases should be amenable to treatment with pho- 
totherapy and radiotherapy. The general health and comfort of the 
patient suffer rarely. The affection is capricious in its course, and 
may on occasions, after long periods of persistence, rapidly improve 
under the simplest treatment. Spontaneous involution, with disap- 
pearance of all symptoms, is reported in some cases. The disorder is 
liable to relapse, though not to frequent recurrence. Its tendency 
to the production of persistent scars should always be remembered 
in formulating a prognosis. Numerous instances of the development 
of carcinoma upon the scar of lupus erythematosus have been reported. 

SYPHILIS. 

(Gr., gvq and QiXog, a companion of swine: term coined for poetical purposes by 
Fraeastor.) 

(Lues Venerea, Morbus Galeicus, Pox, "Bad Disorder." Fr., 
Verole; Ital., Sifilide; Oer., Lustseuche, Krankheit der 
Franzosen ; Span., Sifieis; Swed., Eadezyge.) 

Syphilis is a constitutional, chronic, infectious, and contagious 
disease, transmitted not merely by inoculation but by inheritance. 
It is a malady now recognized in all countries, and has been shown 

1 Cf. Allan, J. C. D., 1903, xxi., p. 510, who strongly advises curetting under 
the edges of the lesion. 



648 NEW-GEOWTHS. 

to be capable of transmission to human beings of both sexes and all 
ages, and also to some of the lower animals. It may last for but a 
few months or endure for a life-time. Further, it may affect more 
or less profoundly every organ and viscus of the body. 

The established facts proving the microbic origin of other infec- 
tious diseases have made it for a long time appear highly probable 
that syphilis is produced by a living organism but in spite of inde- 
fatigable research conducted by experienced observers, the demonstra- 
tion of such an origin has until recently not been perfected. 

In the list of observers whose names have been identified with 
studies in the bacteriology of syphilis, none has been more widely 
accredited with the discovery of the special germ of this disease than 
Schaudinn. In the year 1905, he first distinguished between the 
spirochete refringens recognized in a group of pathological lesions 
having a different origin, and the treponema pallidum, or spirochete 
pallida found only in the lesions of syphilis. Since that date Roux, 
Metchnikoff, and others have extensively confirmed the observations of 
the Berlin naturalist, observations to which a remarkable impetus 
was given soon after by discovery of the fact that the spirochetes 
recognized in the human subjects of syphilis were capable of produc- 
ing the disease in the anthropoid apes. As a matter of fact hundreds 
of inoculations of these animals in series have been made with the 
result of reproducing the disease after the usual periods of incuba- 
tion and with development of lesions in which the spirochaetes have 
been if not invariably at least very frequently recognized. It would 
appear that the germ of syphilis is at last within the grasp of 
science. 

The discovery of the treponema in syphilitic lesions in large num- 
bers and in a sufficient number of observations is effected ; the failure 
to recognize the same in other diseases is established ; the transmission 
in series of the organisms to the uninfected of the lower animals has 
been accomplished. There is lacking yet a knowledge of the methods 
by which pure cultures of the treponema pallidum may be produced. 
As yet no medium has been discovered in which it can be cultivated. 
But its pathological importance at the present date is sufficient to 
place syphilis assuredly in the group of the infectious granulomata, 
and in the increasingly large list of disorders which are produced by 
a single germ and by no other. 

Syphilis has been described as an " imitator of other diseases." 
The manifestations of the malady are certainly protean in character 
and are both like and unlike the symptoms of non-syphilitic affections. 
It is, therefore, more in accordance with fact to describe syphilis as a 
special mode of disease. Its phenomena differ from other pathologi- 
cal phenomena chiefly in the syphilitic modality with which they are 
impressed. After infection there is a different behavior of the living 
matter of which the body is constituted. Its mode thenceforward is 
temporarily changed as regards the process of disease. Hence the 
importance of recognizing this modality in relation to disease of the 



SYPHILIS. 649 

skin, and of ascertaining the limits within which this influence is both 
originated and exhausted. 

Eicord was first to classify the phenomena of syphilis in three dis- 
tinct stages. In the first stage, or primary syphilis, were included 
symptoms relating to the chancre and its accompanying adenopathy. 
In the second stage, lasting from the date of the onset of general 
syphilis during a period of about two years, were grouped symptoms 
that were, as a rule, superficial, symmetrical, and more or less tran- 
sitory. In the third, or tertiary, stage the symptoms included were, 
as a rule, asymmetrical, more profound, involving the subcutaneous 
and deeper tissues, and invading often not merely the skin, but also 
the osseous, cartilaginous, and other structures of the body, including 
the viscera. This simple scheme when first given to the scientific 
world revolutionized all previous conceptions of the disease, and has 
dominated the medical profession up to the present time. 

But there are objections to a continued acceptance of this scheme, 
based largely on its incompleteness. The distinctions it seeks to make 
are wholly artificial, are defined by poor limits, and so often are com- 
pletely negatived that they fail to explain the most important of acci- 
dents. To be consistent and to explain in part the violations of their 
time-schedule, the French have coined such phrases as " precocious," 
" tardy," " galloping," etc. Further, the mind once dominated by this 
scheme was educated to look for the evolution of symptoms within 
each of these artificial stages in a determinate order, e. g., after the 
occurrence of macules succeeded papules ; after these, pustules, tuber- 
cles, etc., a progression rarely observed in any given case. 

Symptoms.^ — The symptoms of syphilis are best studied, as they 
are clinically displayed in distinct departures from the infection- 
moment, along lines which are not fixed, but between which symptoms 
are intermingled with varying shades of severity. The four chief 
classes which may thus be recognized include most of the clinical 
pictures of syphilis : 

I. Benignant Syphilis, with Superficial and. Transitory Symptoms. — 
In this first class the skin-lesions of general syphilis are few and at 
times are even insignificant. A macular rash, for example, over the 
surface of the chest and belly, lasting for a few days or for a week or 
more, accompanied by ganglionic enlargement, after involution, leaves 
the patient for the remainder of life free from obvious signs of the 
malady. These instances are rare. 

II. Benignant Syphilis, with Superficial and more or less Persistent 
Symptoms. — In this class are to be catalogued most cases of the dis- 
ease. Some cases relapse to it from the class previously described; 
others, fewer in number, retrograde to one of the groups named below. 
There is throughout no cachexia, and the skin-symptoms of the affec- 
tion are neither destructive nor deep. Their chief significance lies 
in the fact that they may persist or may recur until the disease, either 
as a result of treatment or of a decline due to other causes, ceases to 
manifest itself by any symptoms whatever. 



650 NEW-GBOWTHS. 

III. Malignant Syphilis, with Profound, Relapsing, or Persistent 
Symptoms that Ultimately Resolve. — In this group are collected those 
cases in which, with persistent or with recurrent symptoms gradually 
involving the deeper structures of the body, the system suffers to the 
extent of exhibiting the signs of cachexia. Patients in this class, by 
reason of efficient treatment or the reverse, are readily transferred 
both to the second class and to the fourth. 

IV. Malignant Syphilis, with Profound and Relapsing, or Persistent 
Symptoms that are Ultimately Destructive. — In this class are included 
the gravest forms of the disease : those exhibiting deep and destructive 
cutaneous lesions ; those implicating the viscera, bones, and other 
structures ; those interfering with the integrity of organs by reason of 
either atrophic or degenerative changes succeeding a circumscribed or 
gummatous involvement of tissue. 

~No one of the groups of symptoms named above necessarily follows 
any other. The last-described group may occur within a few months 
after the appearance of so-called " primary syphilis," even though 
formerly included in the old nomenclature among those of late, or ter- 
tiary, type. Many cases, indeed, of grave syphilis are of the type de- 
scribed by the French as " precocious " ; that is, they develop symp- 
toms of gravity either before or soon after the healing of the chancre. 

CHANCRE. 

(Initial Sclerosis; Indurated Chancre; Primary Sore; Hun- 
terian Chancre.) 

Every attack of acquired syphilis exhibits as a first symptom an 
infecting chancre ; and every infecting chancre points to an oncoming 
syphilis. 

A chancre is that modification of the sound or of the pathologically 
altered skin or mucous membrane, preceded by a period of incuba- 
tion, characterized by sclerosis, and accompanied by adenopathy, 
which constitutes the initial lesion of inevitable syphilis. Chancres 
usually appear upon or about the genital organs simply because these 
organs are most often exposed to the disease. These lesions may, 
however, occur upon any portion of the surface of the body. 

Chancres appear after a period of incubation — an interval of 
time between the date of exposure to the disease and the manifesta- 
tions of its first symptom. This period averages twenty-one days, 
but it may extend from ten days to two months and even more. 

The chancrous modification may involve, as stated above, the nor- 
mal or the pathologically altered skin or mucous membrane. Upon 
previously sound surfaces chancres may appear, after an incubative 
period, as macules, papules, tubercles, erosions, fissures, or ulcers, 
each, or either of which, at some future period of its history is char- 
acterized by a peculiar hardness of the tissues about and beneath the 
lesion, this condition being known as the " initial sclerosis." These 



CHANCRE. 



651 



symptoms vary according to the location of the chancre and the fric- 
tion or other external irritation to which the lesion has accidentally 
been subjected. Generally it may be said that all chancres tend to 
conform to the papular type, the macule developing into the chan- 
crous lesion, the tubercle being evolved from its exceptional enlarge- 
ment, the ulcer from its degeneration, and the erosions or fissures from 
the accidents of its less pronounced features. Occurring upon mu- 
cous or quasi-mucous surfaces these lesions are influenced by heat, 
moisture, and friction (labia, prepuce, etc.). Here the superficial 
erosions are usually circular in outline, are very slightly depressed 
and they rest upon delicate beds of sclerosed tissue, the so-called 
" parchment-induration." The papule is often represented by a tol- 
erably well-circumscribed, macular discoloration of the membrane, 
where coarse examination would scarcely suggest elevation of the sur- 
face, with a sclerosis of no greater extent than that of the erosion, 
with which it probably sustains a close relation. As a result of heat, 
moisture, and friction, however, the typically dry and scaling papule 
constituting the chancre of the integument is here rarely encountered. 
More often the lesion is a circumscribed ulcer with clean-cut walls, 

Fig. 119. 




Initial sclerosis of syphilis (extragenital chancre). 



penetrating deeply to the derma or even below, with a scanty secre- 
tion and a reddish floor, resting upon a split-pea-sized mass of scle- 
rosed tissue. Other usual forms are superficial erosions, in them- 
selves of insignificant aspect, surmounting large nodules, tubercles, 



652 NEW-GROWTHS. 

or even long linear ridges of densely sclerosed tissue, undergoing 
repair or degenerating according to the condition of the patient and 
the treatment to which he has been subjected. These erosions are usu- 
ally out of proportion to the size of the indurated mass upon which 
they rest. Such voluminous indurations are occasionally perforated 
by deep conical or funnel-shaped ulcerations of formidable aspect, to 
which the name " Hunterian chancre " was once applied. 

Occurring upon cutaneous or mucous surfaces, where there has 
been a previous morbid process, the syphilitic mode is impressed upon 
the symptoms significant of such antecedent disease. This accident 
is sufficiently common, and the resulting lesions are as various as are 
those of different diseases. Thus, a man or woman may be infected 
with syphilis at the site of an herpetic vesicle upon the lip or the 
genitals, such vesicle being unbroken and recent, or several days rup- 
tured ; or at the site of a balanitis ; or of a vegetation ; or of the soft 
contagious sore of the genital region best recognized under the term 
" chancroid." Or the inoculation may occur at the site of a trauma- 
tism ; for example, where the f renum is slightly torn in coitus, or 
where the bruised knuckle of the accoucheur is exposed during the 
practice of his art. 

The induration of chancres may precede, accompany, or follow the 
lesion with which they are associated. The sclerosis may be short- 
lived, persistent, or recurrent, and in this respect may resemble the 
chancre itself, which may endure but for a few days, or be in course 
of full evolution at the date of appearance of so-called " secondary " 
symptoms. 

As a consequence, the ganglia in anatomical connection with the 
chancre become, with very rare exceptions, enlarged and specifically 
indurated. With genital chancres there is usually double inguinal 
adenopathy; with labial chancres, submaxillary adenopathy; with 
chancres of the eyelid, pre-auricular adenopathy, etc. The glands 
usually enlarge within a few days after the appearance of the chancre, 
and remain in that condition for several months. They are indur- 
ated on one or on both sides of the body ; are freely movable ; are un- 
attached to surrounding tissues ; are neither painful, tender, nor in- 
flammatory, and they therefore terminate neither by suppuration nor 
by ulceration. It will thus be evident that the word " chancre " is ap- 
plicable only to certain features assumed by other lesions, and is not 
itself descriptive of a lesion differing absolutely from all others. It 
is indeed clear that there can be no particular chancre-lesion, since 
in turn the macule, vesicle, pustule, papule, tubercle, erosion, vegeta- 
tion, ulcer, and fissure may each become a chancre. Every other ele- 
mentary lesion of the skin, therefore, may assume the chancrous fea- 
tures ; in other words, may display in its morbid career the modality 
of syphilis. These chancrous features are : infection ; sclerosis after 
an incubative period; coincident or consequent adenopathy (sclerosis 
of neighboring ganglia) ; and, after a second incubative period, the oc- 
currence of the symptoms of general syphilis. The last-named is, of 



CHANCBE. 653 

course, an historical feature, not recognizable during the greater part 
of the life of most chancres. 

The minor chancrous features are less constant and trustworthy. 
Chancres of the skin may be deeply pigmented. Some are painful 
from the occurrence of inflammation ; some are injured by traumatism 
(chancre of the nipple in nursing-women) ; some, by irritants (caustic 
improperly applied) ; some, finally, are so insignificant in feature 
(chancre of the vagina) that even the expert is readily deceived in 
their recognition. 

With or without involution and complete disappearance of the 
chancre, the symptoms of general syphilis occur only after a so-called 
"second period of incubation." This period extends usually from 
between the end of the first to the end of the second month after the 
appearance of the chancre, the average being between the fortieth and 
the forty-fifth day. During this period the general condition of the 
patient is that which, by subjective and objective phenomena, displays 
signals of the approaching distress of the economy. There are anae- 
mia, and, in cases, even chloro-amemia ; wandering pains, substernal 
or about the articulations; a cachectic appearance; engorgement of 
the superficial and deep ganglia; occasionally a well-marked febrile 
process, the so-called " syphilitic fever " ; and a special irritability of 
the skin and mucous membranes. 

The so-called " periods of incubation " in syphilis do not, however, 
really exist. The words used to define them refer to periods of time 
in which, upon gross inspection, the evolution of the disease does not 
seem to be in progress, but in the course of which there is ample 
evidence that there is a gradual involvement of one organ of the body 
after another. Thus, in the " second incubative period " of the text- 
books careful examination of a patient about to display the external 
manifestations of systemic disease discloses the fact, as suggested 
above, that the symptoms are by no means latent. The glands of 
many parts of the body beside those in the vicinity of the initial scle- 
rosis become tumid and at times painful, including the tonsils and 
thyroid gland. The skin may exhibit icteroid symptoms as a result 
of hepatic disturbances ; the excretion of urea may be augmented or 
albumin may temporarily appear in the urine; pains in the head, 
limbs, and other parts of the body may produce distress even of a 
severe grade; the leucocytes may relatively increase in number; the 
joints may become painful and swollen; and muscular contracture 
with many other evidences of a morbid state of the system may in- 
dicate to the careful observer that a general process of intoxication is 
in more or less rapid evolution. 

It is at this period that what is called " syphilitic fever " occurs. 
In many patients a febrile movement is either unnoticed or absent. 
In others, the temperature may rise two or more degrees above the 
normal, and be accompanied by severe cephalalgia and acceleration 
of both pulse and respiration. A similar condition is recognized in 
some patients much later in the course of the disease. In vet other 



654 NEW-GEOWTHS. 

cases, the fever is accompanied by marked icteroid symptoms and 
with neuralgias of a distressing severity. 

At this moment, the " second period " of the disease being com- 
pleted, the patient is ready for an " explosion " of general syphilis. 
Insidiously or suddenly, first noticed upon the skin beneath the cloth- 
ing, with rapid efflorescence over the entire body-surface after a hot 
bath, the stimulus of liquor, or the excitement of the dance, appear 
the syphilodermata or syphilides or skin-symptoms of syphilis. 

SYPHILODERMATA 

(Syphilides.) 

The skin-manifestations of syphilis are of common occurrence, are 
numerous as to their forms, and are of great importance from a diag- 
nostic point of view. 

As in syphilis of other organs that of the skin is betrayed in 
symptoms like and unlike those of non-syphilitic affections. The 
study of these differences is here also a study of the syphilitic mode of 
disease. In a treatise of this scope and these limitations it will be 
practicable to describe merely those evidences of the syphilitic process 
to be recognized in the integument. 

Lesions of the skin appear in syphilitic individuals of both sexes, 
in all periods of life, and in all stages of the disease. These symp- 
toms are, however, much more frequent during the first two years 
after infection, subsequent to which period the manifestations of the 
disease are betrayed more commonly in subcutaneous lesions, or les- 
ions which affect the viscera, and the osseous, nervous, muscular, and 
vascular systems. 

General Characteristics of the Syphilodermata. — The syphiloder- 
mata, like chancres, are, properly speaking, modalities of such symp- 
toms as occur in diseases not syphilitic. The distinctive difference 
between the papules, ulcers, and other lesions of syphilis and those of 
lupus, for example, lies chiefly in the mode of evolution and involu- 
tion. It is the syphilitic behavior, rather than the syphilitic lesion, 
which guides the diagnostician. The syphilides, in short, resemble 
the lesions of most of the other diseases of the skin, and they differ 
also in various degrees from each one of the latter. Hence is seen 
the importance of a clear recognition of their general characteristics. 

Distribution. — The earlier skin-symptoms of syphilis are usually 
symmetrical, those occurring at a later period of the disease asymmet- 
rical, though in some cases there are exceptions of importance to the 
rule. Predominant sites of syphilodermata are the hairy scalp, espe- 
cially at its borders, the vicinity of the mucous outlets (angles of the 
lips and lids, anal, and genital regions), the palms and soles, the alae 
and root of the nose, the forehead, the interdigital spaces of the feet, 
the umbilicus, and the axilla? and groins. The eruptive phenomena 
of syphilis may be general or few, and either conspicuous and formid- 
able both as to their extent and persistence, or, instead, short-lived and 



SYPHILODERMATA. 655 

insignificant. As a rule, the more general and profuse the earlier 
rashes of syphilis, the more favorable the issue with respect to the 
prognosis. 

Absence of Subjective Sensations. — The eruptions produced by 
syphilis are rarely attended by itching, burning, or painful sensations 
of any sort. This absence is frequently a positive aid in establishing 
a diagnosis, and, as a rule, is the more valuable the graver the lesion. 
Great difference, however, will be noted in this respect between differ- 
ent individuals. Occasionally considerable itching will be induced, 
as in condylomata of the anus ; and syphilitic ulcers, especially of the 
leg, may be productive of severe pain. At the same time it is a com- 
mon experience to find a patient, quite tranquil as regards all subjec- 
tive symptoms, covered from head to foot with a brilliant macular 
syphiloderm, or exhibiting with the utmost composure a large number 
of serpiginous ulcerations on his scalp and extremities. 

Polymorphism, a term used to designate the coincident appearance 
of lesions of various character upon one individual, is as true of 
syphilis as of other diseases, such as lepra and scabies. Viewing the 
cutaneous and other symptoms of syphilis as a whole, this feature is 
strikingly significant, as it is possible to observe at one and the same 
time, upon the body of a single infected individual, symptoms indic- 
ative of pathological changes in the skin, mucous membranes, hair, 
nails, lymphatic glands, and periosteum. 

To a less marked degree is this true of the syphilodermata. The 
type of syphilitic skin-lesions is generally papular, and such lesions 
may originate from macules, enlarge into tubercles, or degenerate into 
ulcers. The simultaneous coexistence of several of these forms is due 
to their chronicity, to their tendency to recurrence, and to the changes 
which they undergo. 

Career. — The historical course of the syphilides suggests certain 
common features. They are rarely accompanied by local inflamma- 
tion, and with the exception of syphilitic fever, are usually un- 
attended with pyrexia or with malaise. The tolerance of the general 
economy of an extensively developed syphiloderm is highly significant 
of specific infection. Again, though generally described as a chronic 
disease, syphilis is, judged with respect merely to time, much more 
acute than several other maladies. The syphilides have a distinct 
career, pursuing, even when untreated, a natural process of evolu- 
tion, and few, save those upon the lower extremities where the force 
of gravity is an important element in the fixation of all local disease, 
persist in unvarying type for any lengthened period of time. One 
lesion often succeeds another by development or by degeneration ; and 
many of the untreated syphilides disappear without leaving relics of 
their existence upon the surface of the skin. In these last-named 
particulars syphilitic cutaneous manifestations are singularly dif- 
ferent from those of lupus and of carcinoma, for example, where the 
lesion is usually of one type, and persists in one location for a period 
of time during which a syphilide would have progressed either to 
much more extensive damage or to permanent repair. 



656 NEW-GROWTHS. 

Color. — There is no color peculiar to the syphilodermata that may 
not be seen in other diseases of the skin. It is important to recog- 
nize this fact clearly, as there are those who claim to diagnosticate 
the syphilides by their hue alone. The color, however, considered 
in connection with the other features of the syphilides, is highly 
characteristic, and often is sufficient to enable one at a glance to iden- 
tify the disease. These color-shades are usually less brilliant than 
those seen in other dermatoses, and they possess less of the scarlet and 
pink quality. They are admixtures of red, yellow, and brown in 
various proportions, frequently with a slight preponderance of the 
brown. They have been compared with the color of raw ham and 
with that of copper, hues which unfortunately have been so associated 
with the syphilides that the non-recognition of such tints has led to 
many errors in diagnosis. Pigmentation in various shades of choco- 
late, coffee, and black is recognized, both during the evolution and 
completion of involution of the syphilodermata. In cases in which 
there has been no luetic affection the color, as in syphilis, is due to 
increase of pigment in the part, both with and without extravasation 
of blood. Recent syphilitic scars are usually pigmented both in cen- 
tre and at the periphery. In these, again, it is not so much the color 
as it is the scar with the color that gives special significance to such 
lesion-relics. 

Contour. — In syphilis the contour of single elementary cutaneous 
lesions, as also of a group of aggregated lesions, is usually circular, 
or there is a distinct tendency to assume such a configuration. Thus 
it is common to find outlines of patches, ulcers, and scars observing 
the curve of a segment of a circle, and the coalescence of several such 
lesions tends to produce the serpiginous aspect. Figures resembling 
a horseshoe, a kidney, a half -moon, the letter S, and a dumb-bell are 
thus produced. The earlier exanthems of synhilis are usually sym- 
metrical, the latter asymmetrical. Even symmetrically distributed 
eruptions will at times occur in annular patches made up of maculo- 
papular lesions arranged in a circular or a crescentic line. Patches 
of syphilitic eruption will often clear at the centre and develop or 
spread at the circumference of a circle. 

Site. — ~No portion of the skin is free from the possibility of in- 
vasion by syphilis. The disease may involve at once almost the entire 
integument ; or it may rapidly spread from point to point, having cov- 
ered finally a large area; or it may appear conspicuously at distant 
and isolated points of limited extent ; or finallv it may be manifested 
exclusively in an insignificant lesion or a group of lesions, ephemeral 
in course and limited to one portion of the body. The site of a 
syphilitic eruption may be determined apparently by the capri- 
ciousness of the disease, and yet result from local irritation of the 
skin of infected individuals. The accumulations on the napkins 
of young women invite the occurrence of labial condylomata ; the lips 
of the infant, after contact with the nipple of the mother, become the 
seat of rhagades and fissures ; while the tongue of the tobacco-chewer 



SYPHILODERHATA. 



657 



and the fauces of the tobacco-smoker acknowledge special sources of 
mischief. 

There are some sites of preference for special lesions, as, for 
example, the squamous syphiloderm of the palms and soles ; and the 
papules of the forehead, constituting the so-called " corona veneris." 

Fig. 120. 




Facial cicatrices of tubercular syphiloderinata after twenty-five years of infection. 



Amenability to Treatment. — Mercury possesses a singular influence 
upon the syphilodermata that is perceived promptly when the drug 
is administered internally. This singularity rests upon the broad 
fact that the lesions of many other cutaneous diseases not only 
refuse to acknowledge the benefit of such medication, but in many 
cases are even aggravated by it. The importance of clearly recog- 
nizing the character of each cutaneous disorder submitted to treat- 
ment is thus well illustrated. 

Character of Special Lesions. — Certain families of symptoms in 
syphilis exhibit characteristic features. Thus, some papular lesions 
are surrounded at the base by a peculiar fraying of the epidermis, in 
consequence of which they are encircled by a little fringe of scales 
resembling in shape a collar. The scales of syphilis are usually not 
abundant, but are fine, dirty whitish or occasionally brownish in 
color. The crusts of syphilis are apt to be bulky, greenish black in 
hue, and to surmount secreting ulcers of various depths. Such ulcers 
are generally circular, or they exhibit in contour a tendency to assume 

42 



658 NEW-GROWTHS. 

the circular line, while the cicatrices by which they are succeeded 
have a similar configuration. The scars of syphilis are frequently 
smooth, delicate, very slightly depressed, unattached to subjacent tis- 
sues, and pigmented. Lastly, from several of the secreting lesions 
of syphilis, especially those upon and about the ano-genital region, 
proceeds a discharge having an offensive odor and capable of com- 
municating the disease to a sound individual. 

Subjection to External Agents. — It is an obvious error to conclude 
that the exanthemata of syphilis are produced exclusively by the oper- 
ation of a systemic intoxication. Many of the pustular syphiloder- 
mata are the result solely of pyogenic cocci, and the extension of the 
eruption may be by inoculation and auto-inoculation. This fact is 
shown not merely by the bacteriological methods of demonstration, 
but also by the clinical fact that these lesions are far more frequently 
encountered among the filthy, the neglected, and the ignorant. Often 
syphilodermata are commingled with seborrhoeic and eczematous affec- 
tions. It is not rare to find patients applying for relief in clinical 
practice who exhibit lesions of syphilis commingled with traces of the 
incursions of lice and bugs, urticarial wheals, scratch-marks, and 
forms of keratosis pilaris, due to the unwashed condition of the skin. 

Syphiloderma Maculosum. — The cutaneous lesions of syphilis, 
limited to color-changes in more or less circumscribed areas of the 
skin, are exhibited in two distinct forms, due respectively to anom- 
alies in blood-supply and pigment-distribution. 

Syphiloderma Maculosum due to Hyperaemia {Erythematous Syphi- 
lide. Macula)' Syphilide, Syphilitic Roseola). — This form of macular 
syphiloderm is the earliest expression of systemic cutaneous syphilis, 
and is more or less constant of occurrence, differing in this respect 
from several of the other syphilides. Often it is unnoticed by the 
patient, whose attention may first be called to it after its recognition 
by the skilled eye of another. It occurs in coffee-bean to filbert- 
sized macules, roundish, oval-shaped, or of irregular contour, and 
varying in color from a light rosy to a dull mulberry hue. In some 
cases these markings of the skin-surface are very indistinct, requiring 
for their recognition close scrutiny in a clear light, and occasionally 
even then leaving uncertainty in the mind of the expert. With a 
lens tinted in cobalt-blue they may be recognized at an earlier date 
than if viewed with the unaided eye especially over the flanks. At 
times they constitute an irregular " marbling " of the surface, of a 
kind which renders it difficult to define with the eye the individual 
lesions composing the eruption, while the general visual effect of the 
exanthem is distinct. The spots are not elevated above the general 
level of the integument, but may change in type, a papular lesion 
developing later in the same site. 

Like all macules of the skin due to vascular changes, those of 
syphilis vary in color with the complexion of the individual, with the 
time which elapses after their first appearance, and with vascular 



SYPHILODEBHATA. 659 

changes in the superficial plexus of blood-vessels. Thus, the deeper 
shades are usually observed in thick and muddy-tinted skins; the 
more delicate tints upon the breast, for example, of blonde women. 

The eruption usually appears between the sixth and the eighth 
week after the appearance of the initial sclerosis, and, when un- 
treated, develops for about one week more. It may be gradual or 
sudden in evolution and persists for a variable period of time, de- 
pending upon the severity of the constitutional disorder and the 
treatment to which the patient is subjected. During the early part 
of its career the hue of the lesions is lighter, and they may be made 
to disappear under pressure of the finger; later, they become hyper- 
semic, are stained more deeply, and exudation having occurred, the 
color of the spot does not disappear under pressure. When involu- 
tion is in progress there is a slow disappearance of the eruption, 
which gradually fades from view. The vascular changes in the 
capillaries occasioned by cold, heat, and rapid cardiac contractions 
influence the eruption to a marked degree. A hot bath, a dance, a 
glass of spirits, a fit of excessive coughing, laughter, etc., may all 
bring the lesions into prominence. 

When the eruptive phenomena have been developed fully for two 
weeks or more, it is rather the rule than the exception to discover 
here and there over the skin-surface large-sized maculo-papules spring- 
ing from the pure macular lesions, or sparsely distributed between 
the latter. 

The eruption may be limited to the skin of the belly, extending 
sparsely over the chest, ■ the loins, the ano-genital regions, and the 
thighs ; may develop over the palms, soles, forearms, and legs ; or, in 
exceptional cases, may profusely cover the entire surface of the body 
(face, ears, dorsal surfaces of the hands and feet, and skin of the 
penis with the progenital region). In the milder forms it is evi- 
dently susceptible to external irritation of the skin, as it is common at 
the wrists where a starched cuff is worn, over the brow in the line 
in contact with the hatband, and is particularly well developed in 
men where the trousers are " reinforced " (perineum and inner 
faces of the thighs). 

At times, as in the exanthematous fevers, the eruption is pre- 
ceded by a febrile state, with marked amelioration of symptoms when 
the rash is fully developed; while, again, it is throughout accom- 
panied by slight rise in the body-temperature, the patient having the 
so-called " bilious" appearance — muddy complexion, coated tongue, 
icteroid hue of conjunctivae, and offensive condition of the breath. 
Wandering pains in the extremities, and especially beneath the ster- 
num, are frequently experienced. The last-mentioned symptom is 
highly significant, and the whole condition is probably due to the 
effect upon the nervous system, of the circulation of the recently in- 
toxicated blood. These pains are not those produced later in the peri- 
osteal and other complications of the disease, and are the more signi- 
ficant as the eruption itself is productive of a scarcely appreciable 



660 NEW-GBOWTHS. 

subjective sensation. The superficial ganglia of the body are usually 
engorged at the same time; the fauces are congested; the hairs of the 
scalp are slightly loosened in their follicles, and in the latter region in 
severe cases papules and pustules may form. Inasmuch as the order 
of sequence of most of the phenomena in syphilis is subject to a sin- 
gular inversion, ii occasionally happens that there is concomitance of 

Fig. 121. 




Alopecia syphilitica (early form). 

later signs of the disease, such as iritis, affection of the nails and 
bones, or even, in special regions, of pustular, papular, or squamous 
syphilodermata. 

Much less rare is the survival of the initial sclerosis to the date of 
this efflorescence. This point is of considerable importance. The 
physician should never conclude the examination of a patient com- 
plaining of suspicious genital lesions without carefully exploring the 
surface of the trunk, and also never pronounce upon an exanthem of 
this sort without minute inspection and palpation of the part where 
an initial sclerosis may exist. In a diagnostic and therapeutic sense 
the information thus gained may be precious, and in a large pro- 
portion of all cases is of a kind hidden from the knowledge of the 
patient. 

Relapses occur in certain cases with limitation of the disease to 
parts previously affected or unaffected. At the end of the first twelve 
months recrudescence of larger macules in annular groups may occur. 
Exceptional forms are noted in which darker puncta appear in the 
macular lesion, occasionally traversed by a hair. These puncta are 
localizations of a more intensely hyperaemic or exudative condition 
about the orifices of the ducts of the follicles. 



SYPHILODEBMATA. 661 

The diagnosis of this syphiloderm is readily established in view 
of its essentially symptomatic character. From scarlatina, measles, 
and rotheln it differs in the indolence of the rash, the absence in most 
cases of decided elevation of body-temperature, and the order of its 
appearance in different portions of the body, as it rarely occurs first 
upon the face. Urticaria and the rashes induced by the ingestion of 
copaiba and other medicaments are distinguished by the marked 
itching of the affected surface and by their very general diffusion over 
the entire body, a condition less often observed in the syphiloderm. 
Tinea versicolor, usually limited to the anterior surface of the trunk, 
is characterized by a fawn-colored to a chocolate-colored tint, by the 
furfuraeeous desquamation which the patient usually describes as 
most noticeable after a hot-bath, and by the existence of the readily 
recognized vegetable parasites upon the scales scraped from the 
affected surface. Tinea versicolor is, moreover, of much longer dura- 
tion than a syphiloderm, and almost never extends to the exposed 
parts of the body — the face and the hands. Ringworm of the skin 
of the body is not symmetrical, and is a parasitic disease. Pityriasis 
rosea occurs in larger, well defined, saffron-tinted, small egg-sized 
patches usually on the trunk only, the long axis of the patch at right 
angles to the vertical axis of the body. The disease is never accom- 
panied by adenopathy. 

All these distinctions, however, are not to be compared in diagnos- 
tic value with the concomitant symptoms of syphilis that are very 
generally present, such as adenopathy, possible persistence of the ini- 
tial sclerosis, and evident involvement of other than cutaneous tissues. 
Such concomitant symptoms will be found occasionally with a non- 
syphilitic eruption due to drugs ingested for relief of the infectious 
disease. The most common of these drugs is potassium iodide ; the 
eruptions it produces are frequently found both commingled with the 
macular syphiloderm and occurring on the eve of the appearance of 
the latter. The existence of acneiform lesions upon the face, the 
neck, and the posterior surface of the trunk, a vivid erythema of the 
forearms, including the hands, and purpura-like maculations of the 
face, legs, and feet, should never mislead the physician as to the char- 
acter of the disorder with which he is confronted. It is undeveloped 
syphilis with a dermatitis medicamentosa of the surface. Suspension 
of the iodide, which drug fortunately is not required in the majority 
of cases, and the use of a properly selected mercurial, or even (and 
this is often wise) abstention from all medication, will be succeeded by 
disappearance of the cutaneous lesions, which may be followed later 
by a mild macular syphiloderm, altogether insignificant in comparison 
with the eruption artificially induced. 

Syphiloderma Maculosum due to Anomalous Distribution of Pigment 
(Pigmentary Syphilide, Vitiligo Acquisita Syphilitica, Leucoderma 
Syphiliticum).- — The eruption, if it may be so called, is relatively 
rare, and characterized by the appearance upon the body-surface of 
irregularly circular, usually poorly defined, dirty-brown and chocolate- 



662 NEW-GEOWTHS. 

tinted macules, which, as they are unconnected with vascular changes, 
do not disappear under pressure. The lesions occur as sparse, well- 
isolated discolorations, or, more commonly after a species of conflu- 
ence, as an irregular rete or network, with relatively large inter- 
spaces characterized by an absence of coloration. It occurs also in 
diffuse stainings of the skin in shades varying from a faint cafe au 
Jait to a deep brown. The eruption is most common upon the sides of 
the neck, the shoulders, and breasts, though it may involve more 
rarely the surface of the trunk and the extremities. It is most fre- 
quenl during the first year after infection, though it may develop 
later. 

It occurs (a) as a sequel to a macular or maculo-papular syphil- 
oderm over the parts described above; and (b) ab origine, as a pig- 
ment-disorder probably under the same influences as those productive 
of the chloasmata of symptomatic origin (chloasma uterinum, cachec- 
ticorum, etc.). In our experience this last is the more usual origin 
of the disorder. 

This manifestation of syphilis in the skin belongs to a group of 
phenomena with respect to which there is doubt whether it be a direct 
product of the syphilitic virus or rather an achromia due to the causes 
efficient in other pigment anomalies of the skin made operative by the 
underlying syphilitic dyscrasia, under the influence of which alone it 
develops. There is good reason for the belief that the latter of the 
two explanations is to be accepted, Fournier, for example, 1 placing 
this among the group of " parasyphilitic affections " described by him, 
the others in the same class being for the most part disorders of the 
nervous system. One of the chief reasons cited by Fournier for this 
association is the well-known fact that the pigmentary syphiloderm 
is singularly insusceptible to the action of antisyphilitic treatment, 
and this although the symptoms are declared usually during that 
stage of syphilis in which the eruptive phenomena are commonly 
symmetrical of development and particularly amenable to an 
appropriate therapy — that is, during the first two years after infec- 
tion. The pigmentary syphiloderm is usually unproductive of sub- 
jective sensations, is more conspicuous in the skin of blonde women 
but more common in brunettes, and in our experience, more fre- 
quently visible on the skins of mulattoes, Mongolians, and Indians 
than among persons of Aryan descent. Though more often affecting 
women, it can be recognized in typical development in adults of the 
male sex. 

The color-changes observed in the skin are explained by the occur- 
rence : first, of pigmentary deposits, possibly at the centre of the ordi- 
nary macular or papular syphiloderm; second, of peripheral absorp- 
tion of such pigment-deposit, with possible persistence of it for a 
variable time at the centre of the lesion ; third, of total absorption of 
all pigment from the original lesion ; and lastly, of peripheral hyper- 
pigmentation of the spaces intermediate between the original macules. 
1 Les Affections Parasyphilitiques, Paris, 1894, p. 12. 



PLATE XXXIII 





























1 
















m 


. 


^L <v' 






■ 


I 






* 




. 1 1 


' * 








^ttdk" 











Miliary Papular Syphiloderm. 



SYPEILODEEMATA. 663 

The eruption is an epiphenomenon of the syphilitic process, being 
rarely amenable to the treatment under which other macular syphilo- 
dermata speedily disappear, and is an expression rather of general 
deterioration of the health of the skin than of specific disease. • A 
chief reason for regarding its origin as wholly distinct from the pre- 
cedence of a syphilitic exanthem is found in the fact that while the 
pigmentary stains, which are relics of syphilodermata, almost invari- 
ably disappear by resorption in the course of two years when of occur- 
rence in the upper segment of the body, the pigmentary syphiloderm 
has been recognized by us as among the stigmata of lues ten years and 
more after infection. 

The eruption is liable to be mistaken for that condition in which 
there is simply an accumulation, upon a somewhat greasy skin, of 
secretions and dust, to be seen upon an integument long unwashed. 
Tinea versicolor has a more yellowish or fawn-colored tint, and, as a 
rule, is developed more abundantly upon the front of the chest than 
upon the neck. Neither vitiligo nor leucoderma is disposed sym- 
metrically, as is usually the case with the pigmentary macular syphil- 
oderm. 

Syphiloderma Papulosum. — The type of all cutaneous lesions pro- 
duced by syphilis is to be recognized in the papule. Most of the 
other lesions are either developed from it, transformed to it, or by 
reversion or admixture confess that the neoplasm of syphilis in the 
skin is essentially a more or less solid circumscribed cutaneous lesion, 
varying as to size and history. 

Papules occurring in syphilis may appear as the first cutaneous 
evidence of infection, or they may be developed from earlier macules. 
They may be small, large, acuminate, flat, disseminated, or in groups. 

Small Acuminate Miliary Papular Syphiloderm (Syphilitic Lichen). 
- — In this eruption the lesions are millet-seed to hemp-seed-sized, cir- 
cumscribed, globular, acuminate, reddish and salmon-reddish, firm 
elevations of the surface, or minute nodules upon the skin, generally 
symmetrically developed, often over the entire body, closely set, and 
occasionally grouped in crescentic figures. When viewed with care 
a minute vesicle, a pustule, or a scale may often be detected at the 
conical apex of each papule, the vesicular or pustular lesions rarely de- 
veloping to such an extent as to become a characteristic feature of 
the eruption. The color is, at first, especially in blonde skins, a 
species of salmon and red mixed ; later, the darker and browner shades 
appear. When generalized, the eruption is well developed, especially 
over the posterior surface of the body, the occipito-cervical and scapu- 
lar regions, the buttocks and the calves of the legs, though it is often 
distinct about the anus and the genitalia. Like several other of the 
syphilodermata, its earlier are more symmetrical than its later mani- 
festations, whether these be tardy or relapsing, or both. Involution 
occurs by resorption of the plastic exudate, minute and usually scanty 
dirty-whitish scales encircling the base of each lesion. When the 



664 NEW-GROWTHS. 

eruption has proved especially persistent, marked pigmentation fol- 
lows in the form of brownish-red blotches, the centre of each of which 
displays a cicatriform relic in the form of a punctum. 

The eruption often is noticed first about the forehead, nose, mouth, 
neck, and shoulders — -localities commonly subject to topical irritation. 
Occasionally the posterior aspect of the trunk, especially the buttocks, 
will be affected extensively. On the face an exceedingly striking 
picture is presented when the papules are grouped in rather vividly 
tinted rings. About the forehead in men the papules will frequently 
be arranged along the surface pressed by the lining of the hat, and 
frequent fingering of the face, shaving, and irritation by the edge of 
the collar of the shirt may determine a more speedy efflorescence at the 
sites of contact. About the mouth tobacco plays the part of an exci- 
tant ; about the nose a localized seborrhoea may be added to the syph- 
ilitic phenomena, in which case the lesions may be covered with thin, 
greasy crusts. The eruption occurs during the first six months after 
infection, and is usually fully developed after a fortnight when no 
treatment has influenced its evolution. It is observed rarely in well- 
treated cases, and is encountered more often when there has been 
ignorance or no treatment of the disease. When the lesions are per- 
forated by hairs they suggest on superficial examination, a resem- 
blance to keratosis pilaris, and when aggregated in patches of distinct 
contour they may be confounded with psoriasis or squamous eczema ; 
but in every case the general physiognomy of the disease may well 
be trusted for the establishment of a diagnosis, having in mind the 
color, the absence of intense pruritus and serous exudation, the dis- 
position over the body as a whole or in portions widely separated, and 
the rarely failing concomitant evidence of syphilitic infection. The 
eruption as a whole is indolent both in evolution and involution, at 
times persisting for weeks, though it is quite amenable to vigorous 
treatment. 

Large Acuminate Papular Syphiloderm. — Lesions of the character 
above described occasionally develop to an unusual extent, attaining 
the size of that of a coffee-bean in localities where the apex of each 
lesion is free to push forward without coming into contact with 
adjacent planes of the integument. Thus, about the dorsum of the 
body, the gluteal regions, the calves of the legs, and the extensor sur- 
faces of the forearms, fully developed, slightly scale-capped or scale- 
encircled, and grouped papules may appear, often commingled with 
pustules and superficial ulcers, the polymorphic patch having a figure- 
of-eight or S-shaped outline. These patches are often displayed by 
patients under treatment the influence of which has interfered with 
the full evolution of the disease. 

Small Flat Papular Syphiloderm. — The lesions recognized under 
this title differ from those just described in that they are not acumi- 
nate, but are distinctly flattened at the apex, this flattening being at 
times so pronounced that each lesion resembles a small button or a 
plaque, the contour being roundish or oval-shaped. The lesions are 



PLATE XXXIV 




Flat Papular Syphiloderm. 



PLATE XXXV 




Flat Papular Syphiloderm. 



SYPHILODEEMATA. 665 

frequently encountered on the face, especially near the mucous outlets, 
over the anterior and posterior surfaces of the trunk, and on the flexor 
aspects of the extremities. The palms of the hands are often affected. 
In color the papules exhibit the variation usual in individuals of 
different complexions, and in the same individual as they are related 
to the condition of the circulation. Thus, on the face a scarcely dis- 
tinguishable pink will become a deep, lurid, reddish brown from an 
attack of sneezing, a paroxysm of laughter or of rage, and from violent 
exercise. The seborrhosic condition noted on the face in the acumi- 
nate lesions is also occasionally seen about the plaques. The same 
is true of the scaling described above. The eruption is much less 
copious, as a rule, than with other forms of syphilitic papules, due 
doubtless to the fact of its subjection to treatment. The papule dif- 
fers from the lesion about to be described with respect to its size, being 
rarely larger than a small button; while the largest papules of the 
same variety may attain the size of large coins. The diagnosis has 
already been suggested. 

Large Flat Papular Syphiloderm. — Here the resemblance of the 
papule to a button is even more distinct, the lesion occurring with a 
well-defined, firm, raised border, and a shallow depression in the 
centre, though at times, especially in moist situations, the superficies 
of each plaque is a smooth, flat plane. The large papules commonly 
begin as macular lesions and rapidly develop at the periphery, this 
development often corresponding with centric involution, by which the 
shallow depression described above is reduced to the level of the adja- 
cent skin and the lesion is transformed into a ring. In shape the 
papules are circular and oval ; in size they vary from that of a finger- 
nail to that of a pigeon's egg. They have the usual variation in color, 
and may scale at the edge, or over the flat top or the depressed centre. 
In moist situations they frequently secrete a muco-purulent fluid 
which is smeared over the papules and adjacent integument, and 
which, in the vicinity of the anus or genitals, exhales an offensive 
odor. It is especially in such situations that flat papules of the type 
described occasionally degenerate by fissure or by circular ulceration. 

Condylomata Lata are flat and secreting papules of the regions 
named, which have a whitish appearance in consequence of the mucoid 
secretion with which they are smeared, and which are transformed 
by the influence of heat, moisture, and either friction or apposition 
of contiguous integumentary folds. 

Papular syphilodermata may become generalized or be limited to 
certain sites of preference, as the face, the neck, the flexor surfaces of 
the extremities, and the ano-genital region. The eruption is either 
an early, a late, or an intermediate symptom "of syphilis, occurring 
most abundantly in young and delicate skins, where the disease has 
been ignored and therefore untreated ; and most scantily in the thicker 
integument peculiar to middle life, where prompt resort has been 
had to appropriate medication. 

Syphilitic papules undergo a series of modifications under the in- 
fluence of various causes which may be enumerated as follows : 



666 



NEW-GROWTHS. 



(a) There is considerable hyperplasia of the cutaneous elements 
(papillary layer of the corium, rete, and blood-vessels), by which the 
papule becomes largely raised from the surface, so as to resemble a 
papilloma, wart, or the lesions characteristic of framboesia. In this 
way, rarely, a portion or the entire surface of the body may be cov- 
ered with light-red or violaceous-red, non-ulcerative, vegetating 

Fig. 122. 




Small flat papular syphiloderma. 



growths. They secrete freely, and the discharge is liable to concrete 
into crusts and to exhale an offensive odor. 

(b) There is considerable hyperplasia of the elements, in conse- 
quence of which the lesions spread laterally, while their elevation 
from the surface is prevented by contact with apposed surfaces. 
Thus is formed the broad, flat, moist papule known as the " vegetat- 
ing mucous patch," "condyloma," plaque muqueuse, etc. (Fig. 123). 
The lesions when unaltered and fully developed, are of a whitish color 
in consequence of the puriform mucus which covers them, and which, 
as with so many of the syphilodermata in moist situations, is liable to 
exhale an offensive odor. When the secretion is removed the lesion is 
seen to be pinkish, or light or dark red in color, and to be either firm 
or soft, scarcely raised, and indefinite in contour, or distinctly elevated 
and well defined. Condylomata are chiefly found in moist situations 
where folds of the skin are apposed, as about the perineum, the groins, 
the axillaB, the mammae, the nates, the anus, the genitals, and the inner 
faces of the thighs. They may coalesce to form palm-sized patches ; 
and the dried products of secretion from the adjacent mucous outlets. 
They are often the source of a considerable pruritus. 



PLATE XXXVI 




Annular Papular Syphiloderm. 



SYPHILODEEMATA. 



667 



(c) Iii consequence of changes in the superficial layers of the epi- 
dermis the papules may become covered with scales, either at the base 
or the apex, more commonly the latter, forming thus the papulo-squa- 
mous syphiloderm. The scales are of a dirty-grayish hue, often des- 
iccated, generally attached, rarely freely exfoliating. They are rela- 
tively few, occurring where the lesions are closely set. The desquam- 
ation may be the most suggestive feature of the patch. Beneath 
the scales are seen distinctly elevated brownish-red papules or merely 

Fig. 123. 




Vegetating condylomata of the vulva and anus. 

slightly elevated, dull-red or purplish-red maculations. When the 
scales accumulate at the base of the papule they tend to surround it 
with a circlet or collarette of exfoliated shreds of epidermis. 

Palmar and Plantar Syphilides.- — In consequence of the thickness 
of the epidermis in the palms and soles the papular or papulo-squa- 
mous syphiloderm of these regions is presented under somewhat atypi- 
cal forms. The dense stratum corneum of the epidermis in the 
palms and soles is not readily raised from its underlying tissue into 
papular forms. The pathological manifestations of this disease are 
rather displayed in thickenings, separations, stainings, and frayings. 

Here, therefore, are seen dull-red maculations, covered throughout 
or merely at the edges, by scales or epidermal shreds; minute, firm, 
corneous thickenings, few or many, often without color in consequence 
of the depth of the blood-vessels beneath the opaque horny layer ; and 
distinctly elevated (not flattened) and circumscribed papules, or 
papulo-tubercles of the usual livid-red color, coffee-bean- to small-nut- 
sized, often aggregated in patches having a tendency to assume the 
circinate outline. Occasionally with a pointed instrument pin-head- 
sized and larger deposits resembling chalk may be pried from circular 



668 



NEW-GEOJrTHS. 



beds in the palms and soles where the lesions first developed. These 
and similar spots often are covered with dirty-whitish, often tenacious, 
half-loosened, epidermic flakes which are characteristic. In other 
cases, usually in consequence of the motions of the hand or the foot, 
or the exigencies of toil, irregular angular losses of epidermis occur 
resembling the fracture of a pane of glass. The attached portions of 
the epidermis project at the edges only, over deep fissures, broad exul- 
cerations, or a ham-red, tender, and newly formed epidermic stratum. 
The eruption is frequently symmetrical in the centre of both the 
palms and the soles but is rarely found upon the dorsum of the hands 
and the feet, and then never developed typically, but always by exten- 
sion from the palmar or plantar regions ; it is also seen on the lateral 
surfaces of the hands, feet, fingers, and toes, as well as over the wrists 
and ankles. The exanthem is a persistent, rebellious, and usually 
late cutaneous symptom of syphilis, occurring often six, eight, and 
more years after infection. Rarely it is seen within a few months 
after the existence of chancre, and is then usually manifested in its 

simpler forms. 

Pig. 124. 




Corymbose papular sypliilide 



The papulosquamous syphiloderm bears in many instances a 
strong resemblance to the patches of psoriasis, but it can usually 
readily be distinguished from the latter by a consideration of the 
following points : 



SYPHILODERMATA. 669 

The syphilid e, as a rule, is not generally diffused ; it displays sym- 
metry only when it involves the palms and soles, and then not invari- 
ably; it is elevated at the border of the patch; and it observes the 
contour of the segment of a circle. Psoriasis is more widely diffused ; 
is generally symmetrical; does not specially exhibit elevation at the 
border of the patches, and the latter are rather more completely than 
partially circular in outline. In syphilis there is generally a his- 
tory of infection, of other cutaneous or mucous symptoms of the dis- 
ease, and, in married women, of abortions, miscarriages, or births of 
diseased children, all of which symptoms are wanting in psoriasis. 
In psoriasis there is a decided predisposition to the development of the 
disease about the extensor surfaces of the joints and the posterior 
aspect of the trunk ; the syphiloderm, though it may occupy these situ- 
ations, can rarely be found thus displayed when other surfaces are 
spared. The scales in psoriasis are more lustrous, are more freely 
produced and shed, and they exist significantly at an earlier period 
of the exanthem. With only such exceptions as prove the rule, 
psoriasis is never strictly limited to the regions of the palms and 
soles. A scaling palmar or plantar disease of the skin in childhood 
is more likely to be psoriasic, though both diseases are seen in the 
early periods of puberty. 

Eczema is recognized yet more readily by its production of itching 
in varying grades, its history of discharge and moisture, and its char- 
acteristic crusts. Ancient patches of squamous eczema are often very 
indeterminate in outline ; they do not ulcerate, and they exhibit scales 
on the surface of a much more deeply infiltrated area. Eczema of the 
palms and soles, when chronic, usually involves also the dorsum of the 
hands and the feet. When this is not the case the eczematous infiltra- 
tion, if of long duration, will in the vast majority of all cases be found 
to involve uniformly and evenly the entire palm or sole, including the 
palmar or the plantar faces of the digits. Eczema, finally, is encoun- 
tered much more frequently solely upon the right hand in right- 
handed patients, or to a greater extent in that organ by reason of its 
preference in the performance of function. This is less common in 
syphilis. 

Syphiloderma Vesiculosum (Varicellaform Syphilide). — Vesicu- 
lar syphilodermata are rare cutaneous symptoms of syphilis if they do 
actually occur. Pinhead- to pea-sized, conical, ploboid, or umbilicated, 
isolated or grouped, and crusting elevations of the epidermis, with 
lucid or cloudy contents, have been observed upon the face, the trunk, 
and the genitalia of syphilitic subjects. The eruption is described 
as an early syphiloderm, often exhibiting a halo of characteristic tint, 
the resulting crusts being granular and somewhat lighter in color than 
those commonly seen in the disease. Both small and large vesicles 
have thus been assigned to the disease, and these, according to their 
resemblance to non-specific exanthemata, have been described as 
varicelloid, herpetic, etc., terms of indefinite characterization. 



670 NEW-GROWTHS. 

V>\\t the larger number of the lesions are, without question, either 
immature pustules, eczematous lesions in syphilitic subjects, or pure 
accidents of the syphilitic process. With regard to the first, it may 
be said that the pustular syphiloderm not rarely begins as a vesicular 
lesion; with regard to the second, that coincidence of so common a 
disease as syphilis with other cutaneous disorders is a matter of fre- 
quent observation ; and with regard to the third, bearing in mind the 
large quantity of potassium iodide swallowed for the relief of the dis- 
ease and its capability of exciting a vesicular eruption, it can reason- 
ably be concluded that some, at least of the cases of so-called "vesicu- 
lar syphilis " have been studied imperfectly. 

Syphiloderma Pustulosum. — In some of the pustular syphiloder- 
mata the pus is neutral ; in others the staphylococcus pyogenes aureus 
and albus are present. The larger number of all pustular affections 
of the skin, whether in syphilitic or in non-syphilitic subjects, are the 
results of infection with pus-cocci. It is therefore not sufficient in 
syphilis to pronounce upon the question of infection only. It is nec- 
essary further to explain many of the external phenomena of the dis- 
ease by the accidents to which non-syphilitic patients are subject. 

These accidents are probably of more frequent occurrence in pus- 
tular syphilodermata than in any other lesions exhibited in the dis- 
ease. Viewed as a whole, it is noticeable that pustules occur for the 
most part in dispensary and hospital practice, among the impover- 
ished, the filthy, the ill-housed, and the poorly treated. They are 
decidedly rare in the clientele of the physician consulted chiefly by 
those who are cleanly, well-nourished, and skilfully treated. If it 
were possible to keep the skin of the syphilitic subject aseptic during 
the management of the disease, no one would expect an evolution of 
pustular syphilodermata at any time throughout its course. The 
lesions described under this title may therefore be regarded for the 
most part as due to the causes suggested above, aided by picking and 
scratching the skin to an extent capable of distributing staphylococci 
over its surface. In other cases it cannot be denied that pustules, 
general of evolution and characteristic in appearance, may develop 
in consequence of luetic infection only ; but even of this type they are 
rarely to be seen in the better class of patients. 

Pustular lesions in syphilis further present a wide range of dif- 
ferences. They may vary in size from that of a pinhead to that of a 
finger-nail ; they may be acuminate, flat, hemispherical, or irregular 
in shape; they may be few or be very numerous; they may be dis- 
tinctly localized or be generally dispersed ; they may be grouped or be 
disseminated ; and they may occur from the first as minute vesico-pus- 
tules or as pustular transformations of variously sized papules. They 
may be surrounded by inflammatory areola 1 , or may spring from an 
unaltered integument, or be subepidermic in situation, and scarcely 
project from the surface. They may be seated upon superficial or 
deep, or sharply cut, secreting ulcers, and they are usually covered 



SYPHILODERMATA. 671 

with crusts differing in bulk and consistency, forming thus the pus- 
tulo-crustaceous syphilide. According to the depth of the ulcera- 
tion at the base are they followed by cicatrices. Pigmentation is a 
frequent result. The crusts which form by the desiccation of pus are 
usually reddish brown to greenish black in hue ; they occur in strata 
or laminae by accretions from beneath, and even when superimposed 
upon a moist and secreting ulcer, they are adherent at the edges. 
They may occur early or late in the disease, and at either epoch may 
constitute trifling or grave cutaneous lesions. They have a marked 
predisposition for involvement of the sebaceous and pilary follicles, 
and they are frequently disposed about the mucous outlets of the 
body. 

Small Acuminate Pustular Syphiloderm (Miliary Syphilide). — This 
exanthem, which usually is diffused over an extensive surface, prob- 
ably represents, as Jullien has suggested, a transformation from 
papular lesions, due to pus-infection of skins that are usually unclean, 
irritated, or the seat of diminished vitality. The eruption is cer- 
tainly rare in patients of the better class. The pustules are recog- 
nized generally about the pilo-sebaceous orifices, and upon minute 
papular lesions, which, as undisguised elements of the eruption, may 
be interspersed among the latter. The pustules are acuminate and 
contain each but a droplet of cloudy serum or pus, the desiccation 
of which furnishes a thin yellowish or reddish-brown crust. The fall 
of the latter exposes the grayish epidermal fringe of the base occasion- 
ally seen in papules of similar size. They occasion little or no sub- 
jective distress save when they occur coincidently with syphilitic 
fever. 

The lesions may be discrete, confluent, disseminated, or in groups 
affecting the curve of a circle. The extremities and the trunk are 
chiefly involved, though the disease may be well-nigh universal. 
Under the influence of treatment occur minute, punctiform, and pig- 
mented cicatricial atrophic depressions which are not persistent. 
The eruption may be an early or a late secondary symptom, but usu- 
ally it is first seen within a few months after infection. Relapses 
occur when treatment has irregularly been pursued. Frequent con- 
comitants are those symptoms of syphilis proper to the period in 
which they appear. Miliary papules often are interspersed among 
the pustules. The eruption aside from uncleanly conditions, is seen 
chiefly in so-called " ignored " cases. 

Large Acuminate Pustular Syphiloderm (Acneiform, Varioliform 
Syphiloderm). — This exanthem of syphilis, sometimes generalized, 
occurring if at all within the first eight months after infection, is 
eminently an expression of syphilis in the filthy skin. It is exceed- 
ingly rare among the better class of patients, and can often be ex- 
plained by the wearing next the skin of coarse woollen, not often 
laundered, undergarments by laboring-men. 

The eruption consists of small or large pea-sized, grouped or dis- 
seminated, acuminate or well-rounded, fairly well-distended pus- 



672 NEW-GEOWTHS. 

tules, which may be seated at the orifices of the pilo-sebaceous ducts. 
The lesions may begin a> reddish macules, pustules, or papulo-pus- 
tules, and may have a tinted border of a coppery hue. The fact that 
sometimes the lesions suggest umbilication has led writers to use the 
term varioliform in their description, an unfortunate term which 
tends to introduce confusion in the description of strictly syphilitic 
lesions. The eruption may be scanty or profuse, be rapid or slow in 
evolution; may develop in crops, and may concur with syphilitic 
fever, as in the instance of the rash last described. When desiccat- 
ing, the pustules furnish a dirty-brownish, occasionally blackish crust, 
covering ulcers of varying depths. The scars left may be persistent, 
but usually lose many of their distinctive features in the lapse of 
time. 

The eruption, aside from the covered skins of the uncleanly, is 
seen also on the face (about the alse of the nose and about the mouth) 
in the subjects of the disease who are cachectic, anaemic, or long given 
to excess in drink and debauchery. 

The diagnosis between this eruption and variola is established 
readily in view of the rapid changes occurring in the last-named 
disease, the febrile phenomena, the order of appearance of the vario- 
lous exanthem, and the evidence furnished by other non-cutaneous 
symptoms of syphilis which are usually present. The drug exanthe- 
mata usually are characterized by more pronounced subjective sen- 
sations ; the several forms of impetigo are seen very rarely elsewhere 
than on the face and hands ; and acne, limited chiefly to the face and 
shoulders, never furnishes a distinct ulcer beneath its crusts, and is 
accompanied by characteristic comedones and other stigmata, over the 
scalp and elsewhere, of a sebaceous gland disorder. The lesions may 
spring from macules or smaller pustules, very rarely from an indu- 
rated or a papular base. They have a thin roof-wall, occurring by 
preference where the epidermis is delicate, and they are surrounded 
by a halo. They are usually acuminate, but after full evolution 
they may flatten slightly at the apex in consequence of partial col- 
lapse. The crusts are bulkier and darker in color than those of the 
lesions just described ; their bases are ulcerated superficially. The 
pustules develop slowly or rapidly, in disseminated or in grouped 
forms, usually at an early period of the disease, though commonly 
after the appearance of some syphilide of another type. 

Small Flat Pustular Syphiloderm {Impetigoform Syphiloderm). — ■ 
This is a relatively frequent manifestation of syphilis, occurring 
upon the face, the scalp, the trunk, and the flexor surface of the 
extremities, usually within the first year after infection. The exan- 
them exhibits a decided tendency to characteristic and circular group- 
ing about the mucous outlets of the body. Such groups are composed 
of small, flat, discrete pustules, pinhead- to pea-sized, originating as 
reddish, macular lesions which tend to dry into flattish, irregular, 
dirty-yellowish or brownish, adherent crusts. These crusts either 
exceed the limits of the diseased surface beneath, or are conspicuous 



PLATE XXXVII 




Large Flat Pustular Sypbiloderm. 




Large Flat Pustular Syphiloderm. 



PLATE XXXVIII 




Large Pustulocrustaceous Syphiloderm of the Scalp 
and Body. 



SYPHILODERAfATA. 673 

upon a dull brownish-red area of inflamed, eroded, and at times even 
of ulcerated aspect. 

Often the pustules are so closely set as to become confluent, in 
which case a single convex crust, like a carapace, will completely cover 
the involved area. Frequent sites of the exanthem are the regions 
about the nose and the lips, as also the chin, cheeks, and the anterior 
faces of the elbow- and wrist-joints. 

The eruption is of pustulo-crustaceous type, and it may be evolved 
from either papular or macular lesions. It is rarely long untreated, 
and is therefore not often presented for observation when in full evo- 
lution. It is usually amenable to judicious treatment ; when followed 
by severe ulceration, destroying an ala of the nose or a part of the lip, 
the patient has usually suffered from either cachexia or neglect. In 
these cases less severe phenomena are presented in the superficial 
serpiginous syphilide, the lesions extending in circinate or annular 
gyrations about a sound or a previously involved and healed centre. 
Thus, a circlet of crusts, with underspreading superficial ulceration, 
perhaps alternating with pustules of various ages and reniform cica- 
trices, will surround the elbow or traverse the scalp. The resem- 
blance to pustular eczema is at times suggestive, but the ulceration 
and outline as well as the absence of itching will aid in their recog- 
nition. The lesions are usually late among the earlier symptoms of 
the disease, but they may be delayed for six months after infection. 
They indicate, as a rule, either severity of the disease, or, much more 
commonly, constitutional impairment. 

Large Flat Pustular Syphilodenn (E chthymaform Syphiloderm). — 
The lesions classed under this title are fully developed forms of 
those described above. They originate as usually numerous, maculo- 
papular lesions, or as nodules or tubercles which gradually deepen 
into pea-sized and even larger flat pustules, the further history 
of which is one of enlarging, blood-mixed, reddish- and greenish- 
brown, also flattish, crusts with underspreading pus-bathed ulceration 
of varying extent. The superficial variety of this syphiloderm is 
distinguished from the deep chiefly by the extent of its ulcer, the size 
of its superimposed crust, and the lighter, dull-red areola which en- 
circles it. 

Pustulo-ulcerative Syphiloderm. — The deep variety, like the super- 
ficial, may be limited to the scalp, face, neck, and flexor aspects of 
the extremities, or it may be diffused much more widely. The en- 
tire surface of the body may be covered with discrete lesions of this 
type in cases of unusual neglect or of profound cachexia. The erup- 
tion is usually of late occurrence, but in the so-called " galloping- 
syphilis " of the Trench it may be precocious in development. The 
lesions are at the onset nodular or tubercular and become transformed 
into pus. They have each a deep infiltrated base with a dark-brown 
halo. Incrustation follows with the formation of a conical, roundish, 
or oval-shaped, blackish-brown crust, beneath which lies a clean-cut 
ulcer, the sharp edges of which are usually exactly roofed by the 

4a 



674 NETV-GEOTVTHS. 

incrustation. The crust thickens by concretions from the foul and 
purulent ulcer beneath, and spreads at the periphery while it thick- 
ens in the centre. In this way the appearance of the stratified crust 
resembles that of an oyster-shell, a condition described by some au- 
thors as rupia, a term once employed as the name of a disease. The 
ulcer, exposed after removal of the crust, is of characteristic syphilitic 
type in its deep base, foul floor, clean-cut edges, and purulent secre- 
tion commingled with blood, at times attaining a diameter of several 
inches, and having a circular, reniform, or horseshoe-shaped con- 
tour. The degree of destruction it may produce is inversely propor- 
tioned to the constitutional vigor of the subject and the treatment pur- 
sued. It is usually a grave and may be a malignant exanthem, 
though under favorable circumstances it is amenable to judicious 
treatment, and may be an early though oftener it is a late symptom of 
the disease. The pigmented scars left are characteristic and indelible. 

Syphiloderma Bullosum {Pemphigus Syphiliticus, an unfortunate 
designation). — Bulla? in acquired syphilis are late and relatively rare 
lesions. They are rarely numerous, pea- to large nut-sized eleva- 
tions of the epidermis, filled at first with a cloudy serum, which soon 
is transformed into pus, often mingled with blood. They have usu- 
ally a characteristic halo about the periphery ; are roundish or oval in 
contour ; are usually discrete, rarely disseminated ; and after develop- 
ment they produce characteristic crusts with underlying ulcers, iden- 
tical in features with the rupioid sequels of large syphilitic pustules. 
The eruption is localized by preference upon the extremities, more 
particularly the lower extremities, and is indolent in its course. It is 
always significant of a cachectic condition in the subject of the disease 
and occurs often in the victims of chronic alcoholism who have been 
infected with syphilis. Its frequent occurrence in congenital syphilis 
is described later. It is to be distinguished from pemphigus vulgaris 
by its characteristic crusts and ulcers, considered in connection with 
the history and associated symptoms of lues. 

Syphiloderma Tuberculosum. — In this eruption which may de- 
velop within the first year after infection, but which often is deferred 
much longer, the lesions are usually multiple, flat, roundish, circum- 
scribed, firm, light-red to dull crimson-red nodules, beginning com- 
monly as macules of a lurid hue. They vary in size from that of a 
coffee-bean to that of a small nut, and involve the entire thickness of 
the skin, often also the subcutaneous tissue. Their surfaces are 
smooth, glazed, or desquamating; and their evolution is peculiar in 
that they rarely exhibit apical pustulation or ulcerative degeneration. 

The eruption is, with few exceptions, usually limited to one or 
more regions of the body, as the forehead, the chin, the nucha, the 
buttocks, and the outer surface of the thighs. It is less often dissemi- 
nated than grouped. Occasionally there may be displayed upon the 
surface of the body but a single tubercular lesion, the recognition of 



PLATE XXXIX 




Tubercular Syphiloderm, Resolutive and Serpiginous. 



SYPHILODEBMATA. 



675 



its character usually demanding some skill on the part of the diag- 
nostician. When occurring in groups the typical circinate appear- 
ance of the syphilodermata in general may be wanting, the patches 
having an irregular boundary; but at times the circular, reniform, or 
horseshoe-shaped outline is distinct, with an enclosed area of integu- 
ment unaltered or the seat of atrophic changes. Whether resolving by 
absorption or degenerating by ulceration they commonly leave typical 
cicatrices of syphilis. There may be complete coalescence of lesions 
with flattening and necrosis or ulceration at one or several points. 
At times the lesions assume a serpiginous character and distribution, 
a condition to which has been applied the term. 

Syphiloderma Tuberculosum Serpiginosum (Circinate Tubercular 
Syphiloderm). — In exceptional cases serpiginous and tubercular 



Fig. 125. 




Ulcerative tubercular syphiloderm 



676 



NEJV-GEOWTHS. 



lesions are marked by secondary changes. They may become covered 
on the surface with a thin yellowish crust; may lose their firmness 
and become soft and rather more lurid red in hue, from colloid, 
or rarely even suppurative, degeneration; may vegetate luxuriantly 
and become the seat, especially on the seal]), of warty growths, 
smeared with a semipurulent secretion of disgusting odor (syphilis 
papillomatosa, syphiloderma framboesioides) ; or finally they may 
ulcerate, the superimposed crusts thickening in bulk, deepening into 
blackish and greenish shades, and covering typical syphilitic ulcera- 
tions, with characteristic edges, floor, base, and secretion. The de- 
generation in the latter case may be rapid and the destruction ex- 
tensive. This result is, however, of rare occurrence. 

The course of the eruption is indolent, months usually elapsing 
before full evolution is accomplished. In untreated cases there is 
produced a generalized and symmetrical syphiloderm. It is rare, 
however, even in hospital and dispensary cases, to observe such de- 
velopment ; the more superficial, generalized, and symmetrical are 
the lesions, the briefer, as a rule, is the interval between such an 

Fig. 126. 




Gummatous syphiloflerm. 



eruption and the date of infection. The later the lesions, the more 
are they asymmetrical, localized, and profound in their involvement 
of the deep tissues. This syphiloderm rarely appears in the second, 
more often in the third or fourth, still more rarely in the fifth, tenth, 
or fifteenth vear of the disease. 



SYPHILODEBMATA. 



677 



Resolution occurs by resorption, leaving in the site of the tubercles 
according to their age, size, and contents, livid and pigmented macu- 
lations, or characteristic pigmented, atrophic, cicatriform areas. 
Scars following the ulcerative lesions are typical in color, shape, and 
career, the pigmentation of both cicatrix and areola blanching from 
centre to periphery, and leaving a delicate, dull-whitish, glazed, or 
slightly desquamating membranous new-growth ; ancient relics of this 
process resembling in appearance thin, small coin- and larger-sized, 
circular sheets of mica. 

Combinations of the tubercles of syphilis with other lesions have 
given origin to the differing terms employed in the designation of the 
eruptive phenomena in which the tubercle plays a frequent part. 
Thus papulo-tubercular, tuberculo-gummatous, papillomatous, or veg- 
etating eruptions are so designated from the admixture of the several 
elementary lesions recognized in these forms of cutaneous syphilis. 

The rarer generalized forms are commonly of simpler type ; the 
circumscribed groups, whether serpiginous or limited to a single 



Fig. 127. 




Tubercular syphiloderm 



region are more often variations from type and confusing to the un- 
trained eye. The affected patch, for example, may be coextensive 
with the surface of an entire limb or buttock ;■ or merely involve the 
nose and upper lip ; or possibly in irregular extension only the face. 
Whether of the resolutive or ulcerative class, the circumscribed 
patches commonly are sluggish in development and career, often 
sprinkled with superficially ulcerated points set in disks of atrophic 



678 



XEJV-GEOWTHS. 



or scar-formed tissue; or again they furnish a ring of ulceration, 
deep or superficial, about a healing centre ; or a group of well-de- 
fined ulcers beset with nodules of papulo-pustular or papulo-tuber- 
cular type. The strictly serpiginous patch extends, whether from 
an ulcerated or partly healed centre, by advancing a ridge of closely 
agglomerated or fused, papulo-tubercles or tuberculo-gummatous 
lesions, crusted, ulcerated, or merely resolving by degeneration when 
treatment has been pursued. The rupioid features seen in the larger 
pustular lesions are displayed here more rarely and less character- 
istically. Even in exaggerated types of the serpiginous patches the 
process in untreated cases is one of advance, repair, ulceration, and 

Fig. 128. ' 




Syphiloma of the vulva with gummatous changes in labia and clitoris, and languettes 
of anus accompanying stricture of the rectum. 



scarring in different grades at different points in the same area. It 
is of striking interest in the study of these cases to note that in almost 
every instance the disease either has been unrecognized and therefore 
untreated, or is one occurring in the subjects of cachexia, debauchery, 
or extreme poverty. Illustrations of these forms of cutaneous syphilis 
are exceedingly rare among the cleanly and well treated. 

The diagnosis is between lupus vulgaris, lepra, epithelioma, acne 
rosacea, and psoriasis. In lupus the age of the subject, the character 
of any scars left upon the body-surface, the chronicity of the disease, 
and the absence of a history of polymorphism, will point usually to the 



SYPSILODERMATA. 679 

nature of the disease. The tubercles of lepra are very much more 
indolent than those of syphilis, and have a characteristic oiled or 
varnished look, never the livid or dull-crimson color of syphilitic 
lesions. Set upon the forehead, the tubercles of syphilis, near the 
line of the hairs, never give the leonine aspect of those at the lower 
border of the forehead and over the eyebrow of the leper. In epithe- 
lioma the age of the subject and the history of the disease are always 
significant. In the early stage of epithelioma characteristic " pearls " 
often may be recognized, while the patient may enjoy excellent 
general health, the imprint of cachexia often being distinct in tuber- 
cular syphilis of the skin. In the later stages of epithelioma the 
ulcer with everted edges and eroded, hemorrhagic floor, " varnished " 
with a translucent secretion, is totally different from the "punched- 
out " syphilitic ulcer with its puriform secretion and discolored crusts. 
The deep infiltration of even the desquamating tubercular syphilo- 
derm distinguishes it from the circular patches of psoriasis. In 
acne rosacea the telangiectases, characteristic redness, and frequent 
pustular lesions are suggestive when considered in connection with 
the absence of ulceration. But, in both sexes, subjects of syphilis, 
with tubercles limited to the nose and head, in the middle periods of 
life often present themselves with marked rosacea from spirit-drink- 
ing, when the most careful examination is needed to detect the coin- 
cidence of the two disorders. 

Syphiloderma Gummatosum. — The gumma is a lesion peculiar to 
syphilis; no other disease exhibits an exactly similar feature. It is 
usually a late or so-called " tertiary " manifestation of the malady, 
but like all other symptoms of the disease may be of early occurrence. 
Gummata occur in two fairly distinguishable forms : the circum- 
scribed, and the diffuse. 

Circumscribed Gummata develop as one or relatively few, subcu- 
taneous, strictly circumscribed, firm, well-rounded, painless, and 
indolent tumors or nodules, which, when first observed, are scarcely 
larger than a pea. They then are covered with an unaltered integu- 
ment and are movable. 

Very slowly they may, when untreated, increase in size until 
they attain the dimensions of a marble, of an egg, or even of bodies 
of a considerably larger size. Sooner or later, when not resolved by 
treatment, they usually become attached, and the overlying skin is 
involved, showing by its livid, reddish, or purplish hue and its 
hypersemic areola that it threatens to yield. Finally, at one or at 
several points the skin is so thinned as to be incapable of further 
resistance, the gumma bursts, and a thick, sanious secretion escapes, 
the gummy character of which has given the lesion its name. When 
the inflammation has been active its secretion may be wholly or 
partially purulent, and in this case be furnished either by the con- 
tents of the tumor or by the peripheral tissue which participates in 
the process. Ulcers always result, which occasionally are fistulous 



680 NEW-GEOWTHS. 

in type, roundish or oval in contour, with edges clean cut, and floor 
purulent and extending to the subcutaneous tissue, tendons, aponeu- 
roses, cartilage, or bone. Thin and yielding bands or bridges of under- 
mined skin often extend between several such solutions of continuity, 
and usually melt down in the presence of the destructive process. 
When repair is progressing, which is the rule as regards the ultimate 
result, granulations spring from the floor of the ulcer, the edges con- 
tract, and the gummatous eventually exhibits the appearance of a 
simple ulcer, save in the thinned, purplish, pigmented appearance of 
the outlying integument. The scars are typical, pigmented at first 
and bleaching from the centre, and they may be attached to peri- 
osteum or bone, though this is exceedingly rare. Considering the 
depth of the process, the gumma of the skin is, as a rule, succeeded 
by less evidence of destruction than is threatened at the height of the 
process. About the neck, cicatrices may be linear in shape and 
slightly puckered. Upon the extremities and the trunk they are 
usually circular or oval. 

But one gumma may appear upon the person of a single indi- 
vidual, and when this is the case it will usually be found upon the 
leg; after this region the forehead is most often attacked. Half a 
dozen or more may at times coexist. In other cases hundreds form. 
Gummata may develop upon any part of the body, more particularly 
over the head (face, nose, lips), the thighs, legs, and arms, the 
scalp, buttocks, and genitalia. When situated over the trunk of a 
nerve they may become the seat of severe neuralgic pain. They are 
amenable to skilful treatment, and they may undergo resorption, 
leaving little or no trace of their former existence. 

Diffuse Gummata. — Diffuse gummatous infiltrations of the skin 
and hypoderm are either distinctly contoured, which is the rule, or 
ill-defined at the border, varying in extent from a coin-sized patch 
to an irregularly outlined infiltration coextensive with the integument 
of an entire limb. The central portion and borders of such an area 
may be constituted of partly fused originally discrete lesions, as in 
the instance of papulo-tubercular lesions, or be made up of a thick 
or thin plate of infiltration, here and there either threatening ulcera- 
tion or besprinkled with actively ulcerating points. In extreme cases 
these losses of tissue are deep and vast, furnishing the picture of a 
group of typical syphilitic ulcers having a sloughy floor and pre- 
cipitous edge. The patch or patches often form curiously outlined 
parts of circles in the classical figures of the letter S, the horseshoe- 
shape, the kidney, etc., these composite groups including equally 
sized circlets of infiltration with border-ulcers ; or a larger central 
patch with gummatous infiltration is surrounded by smaller patches 
set circlewise about the former, as in the arrangement of pearls in a 
brooch. In less classical features there is presented the rare picture 
of a swollen, engorged, almost elephantiasic organ (leg, vulva, nose), 
crusted, corded, ridged, knobbed, and seamed with smaller or larger 
ulcers and scars. 



SYPHILODEBMATA. 6.81 

Gummata are to be distinguished from fibrous, carcinomatous, 
and lipomatous tumors, as also from indurated and enlarged lymph- 
atic ganglia. As gummata of the skin occur in preponderance below 
the level of the knees, and are for the most part single or relatively 
few in such situation, by their position alone they frequently can be 
differentiated from each of the new-growths mentioned, no one of 
which occurs by preference upon the lower extremities. As they are, 
moreover, relatively late lesions of syphilis, a history of pre-existing 
symptoms of that disease usually can be obtained. 

The element of time is of chief importance in the diagnosis, as 
the evolution of gummatous syphilis is more rapid than that of most 
tumor-forming affections. The characteristic " pearls " of epithe- 
lioma and its situation chiefly on the face will serve to suggest the 
diagnosis when there are gummatous lesions of the extremities. 
Lupus of the extremities is rare. Gummata of the face are confused 
most often with the two disorders named above. Invariably in all 
doubtful cases in the male sex the testicle should be examined, as 
frequently a tell-tale gummatous infiltration of the epididymis or 
testicle proper, unrecognized by the subject of the disease, clears up 
the doubt. 

Erythanthema Syphiliticum. — Under this title Bronson 1 described 
a condition observed by himself in syphilitic patients. Upon a well- 
defined, crimson or livid, erythematous surface (face, palms, soles) 
appeared an abundant crop of pea-sized vesico-pustules, which were 
converted later into an exuding, whitish, elevated, diphtheroid patch. 
The multiformity of the exanthem was characteristic. In parts it 
suggested the hydroa bulleux of Bazin ; in other parts the dermatitis 
herpetiformis of Duhring. The fluid exudation that affected the 
face was not characteristic of the evolution of the palmar and plantar 
lesions. 

Later, warty, papilliform lesions appeared over the face and neck, 
somewhat resembling secreting condylomata, and surmounting for 
the most part a dusky-red or erythematous surface. 

This author regarded the exanthem as primarily a syphilitic 
product but not pathologically or etiologically a true syphiloderm. 
Its origin was possibily similar to that of the angioneurotic, tropho- 
neurotic, or reflex phenomena of skin-disorders in general, though 
possibly due to bacterial invasion. 

SYPHILIS OF THE MUCOUS SURFACES. 

The lesions of syphilis involving the mucous membranes, found 
chiefly in the mouth, but exhibited, also, in both acquired and infan- 
tile disease, over the nasal, aural, vaginal, anal, and balano-preputial 
surfaces, are strictly allied to the similar symptoms in the skin. The 
differences are due to maceration of the involved surfaces, to the 
J N. Y. Med. Eecord, 1886, xxx., p. 253. 



682 NEW-GEOTVTHS. 

functions of the organs chiefly implicated, to contact, and to apposi- 
tion of contiguous parts. 

There is, hence, every grade of disorder from hyperemia to in- 
flammation; and the results of the latter are both ulceration and 
cicatrization, each result being subject to the special modifications 
due to the syphilitic process (gummatous deposits, infiltrations, etc.). 

In the purely hypersemic forms there is usually at the moment 
or soon after the outbreak of general syphilis a pharyngeal or a phar- 
yngo-nasal blush, spreading symmetrically or irregularly over the 
parts, accompanied often by engorgement of the tonsils, especially in 
persons previously subject to disorders of the same region due to 
other causes (catarrh, follicular tonsillitis, etc.). There is then pain 
on swallowing, and complications may arise, producing laryngeal 
hoarseness, cough, dyspnoea, aphonia, nasal discharges, crusts block- 
ing up the passages (especially in inherited disease), and impeded 
transmission of air through the nares. Similar conditions may be 
observed about the os uteri, the peri-anal region, and others of the 
sites named above. This may or may not be the precursor of the 
severer complications — mucous patches, ulcers, and other symptoms 
of syphilis of mucous surfaces. 

Mucous Patches (Condylomata; Fr., Plaques muqueuses; Ger., 
Schleimhautpapeln, Feigwarze) are merely syphilitic papules occur- 
ring in moist situations, flattened by reason of the apposition of 
affected surfaces and by contacts necessitated by the functions of the 
parts involved. They form upon all mucous surfaces, but especially 
in the mouth, where they are the most annoying and the most persist- 
ent symptoms of syphilis, complicating both the early and the later 
stages of the disease. 

The patches are roundish or oval, tumid, flattened or very slightly 
depressed, pale-rosy or whitish spots, moistened with mucus, either 
developing as such or resulting from hyperamiic plaques of the sort 
described above, or dispersed among or upon the latter. They often 
resemble the patches produced on the mucous membrane by pencilling 
the latter with a crayon of silver nitrate. When carefully inspected, 
many of them exhibit a loosened and partially detached film of mem- 
brane, covering the tissue, beneath which a reddish, raw-looking sur- 
face appears. They are seen not merely upon strictly mucous sur- 
faces, but develop also on the verge of the latter (mouth, anus, 
scrotum), and even on moistened cutaneous surfaces — the edges of 
nails in infants, and in persons whose hands are often macerated, 
between the toes, in the vulvo-crural angles, etc. The condyloma is 
described by many writers separately, but the older authorities were 
by no means in error when using, as appears above, the term " con- 
dyloma" for both the mucous patch and the flattened creamy-looking 
secreting papules seen often about the anus and the vulva of the sub- 
jects of syphilis, particularly those of a tender age; for the condy- 
loma is actually a flattened syphilitic papule, as is the mucous patch, 
the external appearances of which are chiefly the result of its site 



SYPHILIS OF THE MUCOUS SUBFACES. 683 

The secretions of these lesions are at times very offensive in odor, 
especially about the ano-genital region, but also about the mouth and 
the nose _( infants, the filthy, and the neglected). They may become 
fissured (edges of the tongue, tonsils, vagina), may ulcerate deeply, 
may be the seat of vegetations (papilloma, so-called " esthiomene of 
the vulva," etc.), and, in general, may furnish a highly contagious 
secretion. It is probable that mucous lesions are more responsible for 
the transmission of contact-syphilis than are chancres. 

Mucous lesions are to be distinguished with care from simple 
aphthous patches in the mouth the result of indigestion or local dis- 
turbances; also from smokers' patches (leucoplakia buccalis, " psori- 
asis linguae," leucoplasie) and from lichen planus of the mouth. In 
external features these patches may resemble one another, but in only 
one affection, syphilis, are there other signs of infectious disease. 
The chief points of difference are : singleness, for the most part, of 
aphthous sores, and often exquisite tenderness ; multiplicity, as a 
rule, of mucous patches, and much less soreness, though when ulcer- 
ated the soreness may be a conspicuous feature. Linear streaks and 
bands (often quite insensitive) of leucoplasie patches are found 
especially along the gums, on the lines of the inner cheek representing 
contact with the approximated upper and lower teeth, and in the 
pocket posterior to the wisdom tooth. The flattened and often iso- 
lated patches of lichen planus of the tongue have an almost character- 
istic lead-white color. 

Scaly Patches ("Papulosquamous Syphilides" ; Opaline Plaques; 
Mucous psoriasis) described by most authors separately, are not true 
mucous lesions of syphilis. They occur not rarely in syphilitic sub- 
jects as flattish, smooth, bluish- white or lead- white, firm, slightly 
indurated, and roundish or highly irregular plaques. They are 
relatively painless when not the seat of ulceration. They are visible 
on the dorsum of the tongue, on the mucous lining of the cheeks, and 
at the angles of the mouth, where they are situated often in part on 
the mucous surface and in part on the skin of the lip. The thickened 
epidermis is at times covered with adherent, not readily removed, 
scales between which fissures form, and the patch, at first almost 
insensitive, becomes exceedingly tender and painful. 

These patches are for the most part of the order described above, 
that is, leucoplasie, due chiefly to irritation of the mucous surfaces by 
tobacco-smoke, yet occurring in syphilitic subjects, as they are pre- 
ceded often by typical mucous patches. They are almost exclusively 
seen in men. They are also rarely encountered in inherited syphilis. 
In the distinction sought to be made between the specific and the non- 
specific form attention is called to the occurrence in the latter class, of 
hard, uneven, and considerably thickened patches, which occasionally 
proliferate, and which, extending to some depth, are eventually trans- 
formed into epitheliomatous lesions. 

Gummatous infiltrations of mucous membranes (" sclerosis of the 
tongue," of Founder) occur in both circumscribed and diffused 



684 NEW-GEOWTHS. 

forms, superficial and deep. In the diffuse superficial forms both the 
mucous and the submucous tissues are involved in a firm thickening, 
I" si studied on the surface of the tongue, which then becomes to the 
view polished and smooth, at times appearing as if covered with a 
thin, translucent varnish. Patients exhibiting this condition will 
often describe a subjective sensation of " slipperiness." These thick- 
enings may involve the deeper structures by every gradation, produc- 
ing eventually lobulated masses with intervening fissures, tender, 
raw, and excoriated. The surface of the tongue is then, as a rule, 
covered with a foul, dirty-grayish coat, and it is occasionally notched 
at. the edge with deep ulcers. At times the tongue is mottled, with 
patches of redness alternating with the yellowish white of the deposit 
on the surface of the membrane, and more rarely the tip is covered 
with florid verrucous filiform growths. 

The deeper gummata involve the body of the tongue, and they are 
felt as submucous, diffuse or circumscribed, dense thickenings 
(usually tolerably well defined), which soften, ulcerate, and leave ex- 
posed to view extensive losses of substance. The floors of these ex- 
coriations are deep ulcers, indurated, sloughy, and with membranous 
shreds over the surface. The fissures of the sides of the tongue 
described above may here also produce deeply ulcerated notches in 
the substance of this organ. Deformities of this class are relieved 
markedly after cicatrization, even when considerable loss of tissue 
has resulted. 



SYPHILODERMA INFANTILE ACQUISITUM ET ILEREDITARIUM. 

Syphilis may be acquired by the infant or child at any period 
after birth, as, for example, by immediate contagion from the nipple 
of the nurse, or mediately, as by the use of utensils smeared with a 
secretion capable of transmitting the disease. Such acquired infantile 
disease displays, for the most part, the symptoms observed in adult 
years, except that the delicate tender skin at this early period of life 
often exhibits the moist and secreting lesions of syphilis. The mu- 
cous patch, the pustule, and the condyloma are here more common 
than the papulo-squamous symptoms of the adult. Some influence is 
also exerted upon the disease by the dress, habits of life, and mode of 
obtaining nutriment, which are conditioned upon the helplessness of 
the young child. In this way the soiled napkin over the ano-genital 
region, the warm covering of, and free diaphoresis from, the general 
surface of the skin, and the frequent contacts of the lips with the 
nipple, suffice to determine in special regions particular local expres- 
sions of the constitutional vice. The acquired is much less grave in 
character and portent than the inherited form of the disease. 

Hereditary syphilis, which may be displayed first in infancy or in 
early adult years, is always strictly transmitted by inheritance from 
one or both parents. The consideration of the disease in these pages 
being limited to its cutaneous manifestations, it is first to be noted 



SYPHILODEBMA INFANTILE. 685 

that the infected foetus may prematurely be expelled dead-born with 
cutaneous symptoms displayed upon its body-surface. Over 90 per 
cent, of the products of conception affected with inherited syphilis 
perish in abortions. 

This condition generally argues in favor either of intense syphilis 
in one or both progenitors, or, more commonly, of relatively recent 
infection of both. Under these circumstances there are usually evi- 
dences of the death of the foetus at some date prior to its expulsion, 
the skin being macerated and the epidermis raised from the corium in 
few or many bullous lesions, beneath which the derma exhibits a livid 
reddish or a purplish hue. 

When the infant is born with a clean skin it may be shrivelled 
and emaciated, or be fat and present the appearance of sound health. 
Soon after birth, however, cutaneous manifestations appear, usually 
before the conclusion of the first month, less commonly during the 
second, rarely after the third or fourth. The earlier the date of such 
explosion the more intense, as a rule, is the evidence of the disorder. 
The first symptoms displayed are significant of visceral involvement, 
and are, in brief, those of marasmus. Emaciation progresses rapidly ; 
the skin seems stretched unnaturally over the facial bones ; the ex- 
pression is that of physical distress ; the cry becomes a fretful moan ; 
the integument loses entirely the rosy hue of the healthy infant, and 
acquires instead a sallow or muddy tint; and very peculiar wrinkles 
or puckered lines radiate from the angles of the lips. Few observers 
have failed to notice the resemblance which then exists between the 
faces of these emaciated little creatures and those of the aged of 
both sexes. 

In this complexus of symptoms, however, there is absolutely noth- 
ing characteristic of syphilis as distinguished from other wasting 
diseases of infancy. Chronic tubercular meningitis and the gastro- 
intestinal disorders of infancy in their extreme expression furnish a 
similar picture. This is natural enough, since all depend alike upon a 
similar cause : failure of proper performance of function on the part 
of the viscera in consequence of morbid changes. 

The coryza of the syphilitic infant, however, is soon declared, and 
speedily gives a clue to the nature of the morbid process. The dis- 
charge from the nares (at first serous, later purulent) desiccates suffi- 
ciently to obstruct the nasal passages or, in consequence of the tumid 
condition of the membrane lining the passages, is prevented from 
escaping. Often this discharge is furnished by a specific rhinitis 
chiefly invading the Schneiderian membrane. At times crusts accu- 
mulate externally about the nasal orifices, and they are seen to be 
similar to those which are prone to form also at the angles of the 
mouth. In this way the characteristic " snuffles " of the syphilitic in- 
fant are induced, in consequence of which it is obliged when nursing 
to release the nipple from its mouth in order to respire, an act often 
accompanied by a hoarse cry. The breathing of the syphilitic infant, 
even when asleep, or awake and undisturbed, is often sufficient to 



686 NEW-GEOWTHS. 

arouse a suspicion as to the nature of the disease from which it is 
suffering. The mouth, the larynx, the vulva, and the anus are often 
the seat of similar lesions, the development of which into an obstruc- 
tive tumefaction secreting more or less profusely, or into moist con- 
dylomata, will largely depend upon the seat and surroundings of 
the lesion. 

The cutaneous symptoms of inherited syphilis are macular, papu- 
lar, pustular, bullous, or furuncular, two or more of them being at 
times commingled, attesting thus the identity of the disease with the 
polymorphic acquired forms of maturer years. Macules early appear 
upon the trunk, the face, the neck, and the extremities, usually of a 
livid reddish hue, commingled with papules, and indeed often occur 
as the first manifestation of the papules. They are irregular as to 
shape, and though occasionally pinkish, discrete, circinate, and coffee- 
bean-sized, often produce a diffuse, coppery-red or violaceous, glazed 
or moist and secreting surface, affecting an entire region, as the neck, 
the trunk, or the thighs and the genitalia. Often the palms and soles 
are invaded. Deep excoriations and even fissures occasionally form 
in these extensive patches, and the secretions may incrust them ir- 
regularly, the general aspect of the patch somewhat suggesting an 
eczematous condition, yet remarkably differing from it in color. 

In hereditary as in acquired syphilis the' type of all the eruptive 
symptoms is to be sought in the papules which may spring from the 
macules described above, and develop into pustules, bullae, or condy- 
lomata; and, in the former case, dull-red or violaceous papules of 
lenticular size occur either in asymmetrical or symmetrical arrange- 
ment, being discrete or agglomerated in patches of infiltration. These 
papules may, especially upon the buttocks, scale at the apex; or, par- 
ticularly upon the palms and soles, may constitute by fusion a 
thickened, desquamating, epidermal patch; or, commonly about the 
ano-genital region, the interdigital spaces, the axillae, and face, may 
become moist and secrete a purifonn mucus. By vegetation or by 
hypertrophy they develop into flat or fissured condylomata, smeared 
with an offensive, yellowish or yellowish-white discharge ; and vary 
in size from that of a small coin to a lesion a centimetre or more in 
diameter, with corresponding variation in the degree of their eleva- 
tion from the affected surface. Condylomata may be few or numer- 
ous. Sometimes a child will appear to be well-nigh covered with 
large, moist, secreting papules. Papulo-condylomata may deeply 
ulcerate and crust. It should be remembered, in studying these 
symptoms, that they are those of a cachectic infant affected with a 
grave disease. Death often interrupts the sequence of the manifesta- 
tions above described. This event is usually preceded by signs of 
apparent amelioration, shrinkage of hypertrophic growths, and de- 
coloration of hyperaemic lesions and patches. Of the other cutaneous 
symptoms of hereditary syphilis, vesicles are the rarest ; the smaller, 
occasionally seen, have a conical apex with serous contents, are closely 
set together about the lips, and spring from a violaceous infiltrated 



SYFHILODERMA INFANTILE. 687 

patch. The resulting crusts never have the reddish-yellow tint of 
those observed in eczema, nor, after rupture, are they followed by 
serous oozing from a wounded epidermis. The larger lesions of this 
sort are usually transformations of papules which rapidly assume a 
pustular phase. 

Pustular eruptions, in this form of syphilis, may be discrete or be 
confluent, localized or generalized. They are particularly prone to 
occur in groups about the mucous outlets, with maculo-papular lesions 
developed elsewhere, and they may result in ulceration, often after 
development into bullae with pustular or sanious contents. The re- 
sulting crusts are bulky and dark colored, and, especially upon the 
face, disfiguring. The subjective sensations are insignificant, since 
the child does not attempt to tear the affected surface as in pustular 
eczema. The cachectic condition of the little patient is usually pro- 
nounced when these lesions are large and numerous. They may be 
seen in typical development by the side of the nail, occasionally in- 
volving the matrix, and producing in this situation considerable 
swelling of the digit, with an ulcerative sequel which commonly 
results in distortion or an ultimate loss of the nail-substance. Ony- 
chia, however, may result from perverted nutrition of the part, with 
increase in the friability of the nail-substance, loss of lustre, assump- 
tion of a dirty-grayish hue, and phalangeal cedema. These changes 
are analogous to those resulting in loss of the hair where the follicles 
have been improperly nourished. 

The furuncles which form in other cases are either exaggerated 
manifestations of the same pyogenic tendency^ in the skin of the 
infant, a complication common to syphilitic and other cachectic con- 
ditions in young children, or are the result of infection with pus- 
cocci. These furuncles may be few or be numerous, and they are 
characterized chiefly by their indolence, the ill-conditioned pus in 
their contents, the ulcerative condition left after their evacuation, 
and the bluish or purplish condition of the integument which sur- 
rounds their edges. 

Bullae in hereditary syphilis are early or late manifestations of 
the disease, and they may be represented by a single lesion on the 
palms or soles (the site of their predilection), the fingers, toes, or 
extremities, or they may constitute a symmetrical generalized efflores- 
cence. Bullae should be regarded as evidences of a grave form of the 
disease, being often the precursor of a fatal issue, as indicating a 
feeble resistance on the part of the epidermis to the fluid exudate 
furnished from the corium beneath. In severe cases the bullae are ill 
developed, and the integument will be seen to be marked here and 
there by small coin-sized and larger disks or plaques of macerated 
epidermis, separated from the derma by a thin film of serous, sanious, 
or purulent fluid, in quantity insufficient to raise the roof above the 
general level of the integument. When fully developed they may be 
conical, rounded, flat, or flaccid, and be surrounded by an infiltrated 
border of dark-reddish or violaceous hue. Their color varies with the 



688 NEW-GEOTVTHS. 

color of their contents. In extreme eases they may be distended with 
blood only. Their subsequent career is concluded by shallow or by 
deep ulceration, the floor of each bulla secreting a sanious discharge. 
Crusts may form if the patient survives. A fatal termination of the 
disease is usually announced by flattening or collapse of the blebs. 
The lesions may be commingled with pustules, maculo-papules, con- 
dylomata, and mucous patches of the anus, the mouth, and the nares ; 
but they are somewhat different from the other lesions described in 
that they may constitute a uniform efflorescence, no other cutaneous 
symptoms being manifested. The uniformity is due to the fact that 
bulla? represent the state of feeblest resistance in the epidermis, the 
fluid exudate of exceedingly low grade mechanically separating the 
rete from the tissues beneath. 

Tubercles and subcutaneous gummata may develop in hereditary 
syphilis, but only as late manifestations of the disease, one or more 
years elapsing before their appearance. Their behavior is scarcely 
different from that of those observed in the acquired forms, although 
the destruction wrought by their degeneration in very late manifes- 
tations may be of the most intractable type. Usually there is a his- 
tory of preceding parental or inherited disease, and coincident symp- 
toms or sequels of such disease, in altered teeth (as described by 
Hutchinson), in an ancient keratitis, or in a hopeless form of surdity. 

The special deformity of the teeth first described by Hutchinson 
involves the permanent upper central incisors which when first 
erupted are short, narrow, and thin, but later, by attrition of the free 
edge, present a broad shallow vertical notch. The teeth sometimes 
converge, sometimes are set widely apart and have a dirty hue. 
These teeth are not, as often has been assumed erroneously, pathogno- 
monic of inherited syphilis, but occur typically in the permanent 
teeth of children and adults affected with other disorders. 

Mucous patches are very constant symptoms of the disease, and 
they represent papules of the mucous membrane that differ from those 
seen in the skin only because they are moistened, macerated, and 
flattened by juxtaposition of neighboring tissues. They are sur- 
rounded usually by a lurid halo, and they may have the pearly 
whiteness always seen when the epidermis of mucous membranes is 
wholly or partly detached from the corium ; or they may lose this 
protecting disk in shreds or patches, and show, beneath, an engorged 
or ulcerated and secreting tissue. They may be isolated or be broadly 
confluent, and be oval, circular, or decidedly linear in shape, the 
last-named appearance being characteristic of patches existing at the 
angles of the mouth. Mucous patches are to be recognized as distinct 
from both the parasitic and the non-parasitic forms of simple stoma- 
titis or thrush, the parasitic form being clue to the presence of the 
o'idium albicans. In both of the non-syphilitic disorders the mouth 
of the child is very generally, uniformly, and symmetrically in- 
volved, the circumscribed patches being distinctly discrete and re- 
sembling in color soft whitish or yellowish flocculi of curdled milk. 



SYPHILIS. 689 

They occur not merely in the mouth, but in the ano-genital region, 
between the toes and the fingers (especially the former), in the 
axilla?, groins, buttocks, and folds of the neck. 

The diagnosis always is aided greatly by noticing the well-nigh 
constant occurrence of patches at the angles of the mouth, which has 
also the seamed and puckered appearance described above. Snuffles, 
syphilodermata, and marked cachexia, when established, leave little 
doubt as to the nature of the malady. In all cases when suspicion 
arises the infant should be stripped of its clothing, its entire surface 
be inspected carefully ; all accessible bones be traversed by the fingers, 
the shape of the skull studied, and, in the case of male infants, the 
testes examined for gummatous infiltration. 

The future of the infant affected with hereditary syphilis is not 
always as dark as might be gathered from what has preceded. In 
this, as in the acquired form of the disease, benignancy may be in 
rare cases a conspicuous feature of the entire process. The evolution 
of the disease may be tardy ; its symptoms be few and unimportant ; 
its amenability to judicious treatment speedily be demonstrated. 
Still, the fact remains that the disease when inherited is far graver 
than when acquired, the victim of inheritance entering the world 
with its viscera and bones subject to profound pathologic alterations. 
Attention has been directed to the important fact of the frequency 
with which the syphilitic product of conception perishes. 

Etiology. — Syphilis, in the course of which appear the syphilo- 
dermata, is produced by either accidental or intentional infection, or 
as a result of heredity. In all cases it is believed that the contagium, 
which reaches the blood through the medium of the lymphatics, 
is effective by reason of a virus charged with the special germ of the 
disease or its toxines. The physiological secretions of the infected 
uncontaminated with pathological products are believed to be in- 
capable of acting as virus-carriers, but, especially in the recently 
infected, such contamination is of frequent occurrence, and is gen- 
erally effective in the transmission of the malady to persons not 
immunized by previous attacks of the disease. 

The methods of transmission may be immediate, as in sexual con- 
gress, in kissing, and in nursing at the nipple, by which act the child 
may infect the nurse with the secretion of the mucous patches in its 
mouth; or the infant may, instead, receive the disease from excoria- 
tions on the breast of the nurse. The disorder may also result through 
the medium of utensils charged with an infectious secretion, such as 
the needles of the tattoer wet with saliva commingled with diseased 
mucus, or the lancet of the vaccinator covered with an intoxicated 
blood. Generally it may be said that all the discharging and moist 
syphilodermata are sources of danger to a sound individual, both in 
the acquired and the inherited forms of the disease. 

By these and other similar methods persons of both sexes and all 
ages may become infected. 

44 



690 NEW-GROWTHS. 

However begotten, the syphilodermata are yet not excluded from 
subjection to the long list of external irritants which may in turn 
annoy the skin. The influence of a hot bath, or the excitement and 
perspiration in the dance, will often invite to the surface a macular 
syphilide which might otherwise be less fully developed ; friction, as 
by the hatband over the forehead, the cuff at the wrist, and the shoe 
upon the foot, demonstrates its influence by daily examples of deter- 
mination of the morbid process to special localities. In the trades 
the hands of the syphilitic laborer betray unmistakable evidences of 
the irritative effect of harsh contacts ; the same may be said of filth, 
such as the feces on the napkin of an infant that frequently provoke 
condylomata in the anal region. It is a mistake to suppose that syph- 
ilis, and syphilis only, is responsible for the exanthemata of that dis- 
ease in all shades, grades, and situations. Soap and water are as effi- 
cient in preserving the skin of the syphilitic as of the sound subject; 
and the infected tobacco-chewer pays a price for his nauseous habit. 
Poverty, misery, and wilful neglect or ignorance of the laws of hy- 
giene, are responsible for a long and lengthening list of the complica- 
tions of the disease. 

Pathology. — The search for the micro-organism responsible for 
syphilis has been conducted by numerous and skilful observers. Be- 
ginning with Donne in 1837, the list includes the names of Hallin 
(1869), Salisbury and Briihlkens (1870), Klebs, Lostorfer, Ber- 
mann, Cutter, Aufrecht, Obraszow, Lustgarten, v. Niessen, Schiiller, 
Jullien and de Lisle, Joseph and Piorkowski, and others. 

No investigation of the etiology of syphilis, however, has been 
crowned with the success, now practically amounting to a demonstra- 
tion, which has culminated in the recognition of the treponema palli- 
dum, first described by Schaudinn and Hoffman, as the essential 
cause of the disease. Since the first publication of the results of their 
labors the accumulated proofs in confirmation have given rise to a 
literature including more than four hundred separate treatises and 
papers. 

In a brief summary of the determined facts, it is here merely 
needful to set down: first, that the new syphilis parasite has been 
recognized in the enormous majority of all lesions examined by those 
who have acquired the requisite expertness, in chancres, in early 
and late superficial syphilodermata of acquired disease; in the cuta- 
neous lesions of inherited syphilis ; in the blood ; and in many of the 
internal organs of the body. The treponema has been transmitted in 
generations to the lower animals, more particularly to the anthropoid 
apes, and has further been recognized in artificially produced lesions 
of these animals in successive generations. Prom these, the disease 
has been transmitted to man as a result of accidental contacts in two 
conspicuous instances; and in these human cases the delicate spiral 
organism has been recovered. The practical aspects of this discovery, 
together with the possibilities now largely discussed among experi- 
menters, as to the possibility of securing a serum capable of relieving 



SYPHILIS. 691 

the disease or of conferring immunity against its ravages, are not yet 
fully determined. 

The treponema pallidum is a long, helicoid, and mobile parasite 
belonging to the family of spirillaris, a family consisting of several 
members which have long been recognized in recurrent fever and 
other disorders. 

The spirals of the spirochete have an average length of 11.14 
microns, with an average number of windings of 10.2, the curves 
forming arcs of small circles. One extremity is thicker than the 
other, the thinner and slenderer terminating in what Schaudinn has 
termed a flagellum. Atypical forms are recognized in which the 
spirals for some distance in the organism are wanting; others are 
shorter and thicker ; some have distinctly bulbous extremities ; yet 
others are closely intertwined for some distance of the length; again, 
in cases there are faint indications of transverse division. 

The common staining methods are: Giemsa (fixation for ten 
minutes in absolute alcohol and from one to two hours staining) ; 
Goldhorn's borax methylene blue ; Wright's blood-stain ; filtered solu- 
tion (saturated aqueous) of gentian violet; iron-haBmatoxylin ; and a 
modification of Levidati's method by silver precipitation (H. Fox). 
For diagnostic purposes the Giemsa stain is most commonly employed. 

The treponema pallidum has never been found in non-syphilitic 
lesions; but is not present in all syphilitic tissue. It is often 
recognizable in inherited syphilis (viscera, skin, bronchi, bileducts, 
urine) . In the inital sclerosis of acquired disease, it is usually 
present, as also in mucous patches, enlarged glands, and in the early 
symmetrical exanthemata. In malignant disease and in late gum- 
mata it is more rarely encountered. 

Siegel's Cytorrhyctes luis, 1 also claimed as the effective agent in 
the production of syphilis, is much more difficult of demonstration. 

The histopathology of syphilis rests upon fewer absolutely dis- 
tinctive changes than those recognized in other diseases and even than 
in some other members of the group of infectious granulomata. 2 

It is believed by Hoffman that the treponema obtains access to the 
general economy through the lymph-spaces of the rete ; whence being 
protected from phagocytosis, it advances to the lymph-vessels of the 
papillae. The subsequent changes are in the direction of endo- and 
peri-lymphangitis with consequent fine new-vessel-formation, con- 
nective-tissue hyperplasia, and infiltration. According to Ehrmann, 
however, the lymph vessels are only secondarily involved, the primary 
changes occurring in the connective tissue interspaces. 

The structural alterations in initial scleroses are : increase of 
blood-vessels with connective tissue changes in walls ; plasma-cell 
infiltration; involvement of connective tissue; and lastly, secondary 

1 Fischer, Berl. klin. Jour., 1907, Heft 223. 

2 Eecent Literature: Die Aetiologie der Syphilis, Hoffman, Berlin, 1906, with 
two plates; Fordyce, Vessel-changes and other Histologic Features of Cutaneous 
Syphilis; J. A. M. A., 1907, Aug. 10, p. 462, with 12 microphotographs : Neisser, 
Die experiment. Syphilisforschung nach ihr. gegenwart. Stande, Berlin, 1906. 



692 NEW-GKOWTRS. 

epidermal involvemenl ( Fordyce). The erosive features of certain 
chancres are due to central necrosis; in the rare phagedenic chancres 
the disintegration is due cither to the results of secondary infection, 
to weakened resistance, or to improper treatment. Involution of 
chancres is by fatty retrograde metamorphosis. 

The macular syphiloderm is, according to Fordyce, rather embolic 
than toxic in character; and the same is true of the papule. The 
former represents a mild reaction from the encroachment of the tre- 
ponema upon the distal capillaries of the papilla?, the epiderm re- 
maining unchanged or becoming flattened by compression, with dis- 
appearance of the ridge-system. In the upper corium there is 
moderate vascular dilatation with ensheathment by moderate round- 
celled infiltration. The adventitia of the larger vessels exhibits a 
swollen endothelium where are also round and spindle-cells. 

The small miliary papule is the result of a follicular process ex- 
tending from the epidermis into the corium below the hair-papilla. 
Here also are new-formed vessels in a reticulum about the follicle, 
which include round-, plasma-, and connective-tissue cells. At the 
periphery, the vessels are blood-filled; nearer the centre they are 
obliterated ; some become the seat of thrombosis ; still more externally 
the vessel-walls are merely thickened. The coil-glands and erectores 
muscles participate to some extent in the process. 

In the large papular syphiloderm occur parakeratosis, acanthosis, 
oedema, and development of polynuclear leucocytes with frequent 
mitoses. The cellular infiltration is limited at first to the vessels in 
the upper corium. 

Between the large papular and the tubercular syphiloderm alike, 
the distinctions are chiefly connected with the extension of the one 
morbid process to the relatively deeper portions of the integument. 
Epithelial hyperplasia, altered blood-vessels, cellular hyperplasia and, 
in the larger lesions, actually plasma and giant-cells, with lymph- 
ocytes and hyperplastic fibroblasts are recognized. The vessels as 
usual are the seat of an obliterating endarteritis, their former site 
being indicated by solid cords, groups of irregularly disposed cells 
with faintly stained nuclei and giant-cells, with peripheral or cen- 
trally stained nuclei or both. About the smaller lesions (papules) 
vessels and coil-glands are embedded in a degenerated connective 
tissue reduced to a fibrillary net-work, the cellular exudate contain- 
ing some round and plasma cells. 

Vesicles, pustules, and bullae are of exceptional occurrence in syph- 
ilis, being seen chiefly in the very young, in the very old, in cachectic 
subjects, or as the result of accidental and secondary infection. 
These lesions form, as a rule, at the apices of papules, and in some 
cases are caused apparently by an unusual intensity and rapidity of 
the infective process. Destruction of the cells in the centre of a papule 
may result in a pustule or superficial ulcer. The coexistence of sebor- 
rhea in some of its phases is responsible for the crusting of many of 
the papular and tubercular syphilides. 



SYPHILIS. 693 

In gummata, the changes are simple extensions and exaggerations 
of the same process ; diffuse infiltration, formation of necrotic foci, 
vessel-wall thickening, and eventual obliteration. The infiltration 
consists of lymphocytes, plasma-cells, and many hyperplastic fibro- 
blasts. 

Diagnosis.- — Tn seeking to establish a differential diagnosis by 
purely histological findings, tuberculosis, lichen scrofulosorum, lepra, 
blastomycosis, epithelioma, and sarcoma are chiefly to be excluded. 
In blastomycosis and lepra the microscope readily establishes the fact. 
The lesions of lupus, however, are often difficult of recognition as 
such. In syphilis, Fordyce lays stress upon the greater degree of 
proliferating endarteritis and other vascular changes, the incomplete- 
ness of the giant-cells, and the rapidity of metamorphosis in both 
retrogressive and proliferating processes. Of the drug eruptions 
most liable to be confounded with syphilitic lesions, the most common 
is that produced by ingestion of bromide of potassium, lesions which 
the clinician should learn to recognize. In these odd-looking papil- 
lomatous lesions, Fordyce calls attention to their remarkable epithe- 
lial hyperplasia, the miliary abscesses, and the diffuse infiltration 
made up of round and polynuclear cells, often with eosinophiles scat- 
tered through the derma. The absence of giant-cells and of vascular 
sclerosis are noteworthy. 

In sarcomatous lesions, small-celled growths with interspersed 
vascular spaces, minute haemorrhages leaving pigment sequelae, and 
numerous mitoses, distinguish the idiopathic hemorrhagic type; 
while in other forms, the occurrence of spindle-cells deeply situated 
in the corium with giant-cells interspersed in a delicate reticulum, 
commonly suffice to establish the diagnosis. 

The syphilodermata are to be distinguished from all other cuta- 
neous eruptions by their general characteristics and by the features 
peculiar to each lesion. It must not be forgotten, however, that these 
lesions are not essentially different in character from all others, but 
are to be recognized with ease or with difficulty according as they 
do or do not betray the syphilitic expression. ISTo one, however expert 
in diagnosis, can always trust himself in a doubtful case to recognize 
these special features by a study of the eruption only, at a given 
moment of time. Neither in respect to color, form, size, situation, 
disposition, or other peculiarity do the syphilodermata exhibit an 
absolute difference from non-syphilitic affections of the skin. It is, 
therefore, requisite in every case to investigate in the fullest manner 
the history of the disease, of all prior skin-lesions, of a primary scle- 
rosis (when this can be obtained), of adenopathy, miscarriages, abor- 
tions, and disorders affecting other organs of the body, as the bones, 
the viscera, the organs of sense, and the mucous surfaces. Often a 
single extra-cutaneous symptom is a valuable aid in establishing the 
diagnosis of syphilis. An "eczematous" infant with snuffles and a 
hoarse cry has been treated in vain by many a physician, otherwise 
capable of making a diagnosis, who might have been given a clue to 



694 NEW-GEOWTES. 

the nature of the disease from which the child was suffering if he had 
taken pains to inspect the anus and question the father in private. 
It is especially noteworthy that syphilis is very rarely a disease with 
cutaneous symptoms only. The hones, viscera, testes of male patients, 
and mucous membranes rarely fail to give evidence of systemic in- 
fection when lues has existed for any length of time with active cuta- 
neous manifestation. 

The distinction between syphilis and yaws 1 is of importance in the 
countries where the last-named disease is relatively common. Yaws, 
unlike syphilis, acknowledges a special topographical habitat; it is in 
general not of venereal origin, often attacking children but in infants 
never before the twentieth or thirtieth day after birth ; its incubation 
period is variable ; there is no constant primary lesion ; the character- 
istic yaws symptoms are conical elevations of the surface with an 
erythematous ring at the base ; there is no alopecia, no involvement of 
mucous surfaces, no iritis, and no visceral lesions. Lastly the victim 
of yaws may incur syphilis. Both disorders are produced by a variety 
of spirochete; yaws by the spirochete pallidula. 

Every syphilitic patient ivith a disease of the skin does not neces- 
sarily exhibit syphilodermata. The course of the disease in many 
cases is so protracted that patients have ample opportunities to con- 
tract other disorders, and. their number is larger than is commonly 
supposed. They suffer most often from the medicamentous eruptions, 
especially those induced by the ingestion of potassium iodide (cf. the 
chapter on Dermatitis Medicamentosa : Drug-eruptions from Salts of 
Iodine) ; they are, like other men and women, bitten by bugs and 
lice; and they suffer from eczema, acne, psoriasis, and other non- 
venereal disorders. This common susceptibility is less true possibly 
of the innocent victims of the disease than those guilty of sexual 
excesses in and out of the married state, many of the unmarried lead- 
ing the most disordered lives, and exposing themselves to the ordinary 
causes of disease to a degree not noted in other persons. 

It is always necessary, therefore, in making a diagnosis in a case 
supposed to be syphilitic, first, to determine ab origine the fact of 
syphilis ; and, if that fact cannot indubitably be ascertained, to be 
careful that the statements of the patient are not allowed to bias the 
judgment in pronouncing upon any eruption present; second, suppos- 
ing that such a fact is established by clinical proofs without reserve, 
to decide whether the eruption present is produced by the existing 
syphilis or some other externally or internally operating cause ; and if 
this last be determined, to be careful in eliminating the syphilitic 
influence from its operation. 

Ignored syphilis is usually severe; but it is without avail that 
disorders of a different character are treated by the methods useful in 
syphilis. Thousands are annually thus mistreated who might have 
been spared such a calamity. The frequent occurrence, after a suspi- 
cious exposure, of a balanitis, of an attack of progenital herpes, of 
1 Beurmann and Gougerot, Eev. de Med., 1907, May 10. 



SYPHILIS. 695 

uninfected excoriations, of blennorrhagic discharges, and even the 
appearance of molluscous tumors, warts, or parasitic cutaneous dis- 
orders upon the genital region, is a source of alarm and of fruitful 
error to the many rather than to the few. 

The diagnostician none the less must ever be on the alert to recog- 
nize the symptoms of the disease in those who least suspect it. Thus, 
married women complaining of a " humor of the blood," men who 
have been " overheated and broken out with a rash," and a long list of 
patients exhibiting upon their persons the symptoms of " salt rheum," 
" lupus," " tetter," " scrofulous ulcers," and " erysipelas " are those 
whose speedy relief will depend upon the skill of the practitioner in 
recognizing the precise nature of the malady. 

The diagnosis of syphilitic lesions of the skin is a matter of the 
very greatest importance, inasmuch as the health, comfort, mental 
happiness, and domestic relations of thousands of men and women 
annually depend upon it alone. An error in either direction may in- 
volve the most serious consequences to both physician and patient. 
He is but poorly qualified to discharge the important duties of a 
general practitioner of medicine who has not carefully trained him- 
self to establish the truth in these cases, irrespective of the diagnosis 
of the patient and of all others who may have been consulted. 

Serum Tests, — The diagnosis of syphilis by serum tests requires 
special skill in the management of its technical details as also access 
to much clinical material. The test elaborated by Wassermann, 
Neisser, and Bruck, 1 and by the same experimenters in connection 
with Schucht 2 is conducted as follows : 

An extract is prepared with salt solution from the organs of a 
syphilitic foetus to which is added a small quantity of the spinal fluid 
of the suspected person heated to 56° C. with a view to destruction 
of what is known as its " complement," the latter being later pro- 
vided by serum from a normal guinea-pig. After exposure for one 
hour in an incubator, the syphilitic antibodies in the spinal fluid 
(if these be present) combine with the treponema substance of the 
extract, and unite with the complement derived from the freshly 
added serum. There is left no free complement ; as shown by remov- 
ing a small amount of serum from an animal immunized against the 
red corpuscles of another of its kind, heated to 56° C. and mixed 
with the supposed syphilitic mixture. If the complement of this 
mixture has been all combined by the syphilitic antibodies, the 
heated hemolytic serum has not been activated, and has no power to 
hemolyze red corpuscles. 

The Wassermann test is fully described by Fleischmann and 
Butler, 3 and endorsed by them after careful experimentation, as also 
by Hoffman and Blumenthal, 4 Finger, 5 and others. 6 Yet the equally 
J Deutsch. med. Wochscft., 1906, xxxii., 745. 

2 Zeitschft. f . Hyg. u. Inf ektionskrankh., 1906, lv., 451. 

3 J. A. M. A., 1907, xlix., Sept. 14, p. 934. 
* Derm. Zeitschft., 1908, xv., p. 23. 
5 Wien. klin. Wochschft., 1908, No. i. 

9 A practical modification of the Wasserman test has been devised by Noguchi : 
Jour. Exper. Med., 1909, xi., p. 391. 



696 NEW-GBOWTHS. 

careful work of Wollstein and Lamar 1 has led them to the conclusion 
that '"neither by the complement-binding method, nor by the method 
of precipitation as at present carried out, is it possible to show the 
presence of antagonistic substances in the blood-serum of patients in 
the secondary stages of syphilis, on the one hand; and in the tertiary 
stages of Byphilis on the other; or in such parasyphilitic affections as 
tabes and paresis." The prospect that an absolute determination of 
the period when syphilis no longer has left traces of its existence in 
the system, is still clouded with uncertainty. 

Treatment. — Metehnikoff's formula for the prevention of syphilis 
is 33 grains (2.) of calomel, added to 67 (5.) of lanoline and 
10 (0.66) of vaseline. The ointment is claimed to be effective only 
when thoroughly rubbed into the infected region during the first few 
hours after exposure, but experiments on monkeys have demonstrated 
that a single injection of atoxyl, employed at any date before the fif- 
teenth day after infection is capable of preventing the occurrence 
of the disease. Prophylaxis in man is claimed to have been secured 
by two injections of atoxyl of ten grains (0.66) each at intervals of 
two days. In these cases, however, there was simply a dread of in- 
fection and no conclusions can be drawn from the experiment. 

The syphilodermata are to be treated by topical applications 
intended to hasten their disappearance or involution ; but as local 
manifestations of a constitutional disease, their management is largely 
that which looks to the relief of the latter. 

The treatment of syphilis, in the pages which follow, is described 
in outline, so far as it relates to the relief of cutaneous lesions and of 
the systemic condition. The important modifications of therapy that 
are required in the management of syphilis of the osseous and the 
nervous systems, of the respiratory, gastro-intestinal, and other 
organs, it is scarcely necessary to remark, are fully described in the 
standard treatises specially devoted to this subject. Among them 
may be named, as of American authorship, the works of Taylor, 2 of 
Morrow, 3 of Keyes, 4 of Hyde and Montgomery, 5 of White and Mar- 
tin, 6 and of Bangs and others. 7 Of those more or less recently pub- 
lished abroad may be named Power and Murphy's System of Syph- 
ilis, 8 the standard treatises of Jullien, 9 of Fournier, 10 of Diday and 
Doyon, 11 of Mauriae, 12 of Neumann, 13 and of Lang. 14 

J Arch. of Intern. Merl., 1908, i., p. 314. 

2 Pathology and Treatment of Venereal Diseases. Philadelphia, 1900. 
^ System of Genito-urinary Diseases, Syphilis, and Dermatology. New York, 
1893 (3 vols.). 

4 Surgical Diseases of the Genito-urinary Organs, including Syphilis. Xew 
York, 1888, and E. L. Keyes, Jr.. N. York, 1908. 

5 Syphilis and the Venereal Diseases (2d edition). Philadelphia, 1900. 

6 Genito-urinary Surgery and the Venereal Diseases. Philadelphia, 1897. 

7 American Text-book of Genito-urinary Diseases. Syphilis, and Diseases of the 
Skin. Philadelphia, 1898. Cf. also a recent and valuable paper on the Treat- 
ment of Syphilis, by George Pernet, B. M. J., 1907, Mar. 30, p. 730. 

s Six vols., London, 1908. 

9 Traite pratique des Maladies veneriennes. Paris, 1886. 

10 Leqons Bur la Syphilis, etc. Paris, 1873. La Syph. Hered. tard., 1886. 



SYPHILODEEMA INFANTILE ACQUISITUM. 697 

The first and often the most important consideration for the prac- 
titioner who is in face of a syphilitic patient is the care of that 
patient's general health. Simple and natural as it may he to set down 
such an injunction in this connection, its importance rests upon the 
fact that it is too often neglected. Patient and physician respectively 
are often hurried into the precipitate ordering and swallowing of spe- 
cific drugs without regard to other as important details. 

It is well to hand to the patient, at the outset of all treatment for 
syphilis, a slip of paper on which are printed in concise and simple 
terms a set of rules to be observed during the continuance of the dis- 
ease. For physicians who do not take similar precautions it is advis- 
able to enter rather fully into the explanation of certain details which 
the patient should be made to understand. 

He or she, if an adult, should, as a rule, be informed of the 
serious nature of the disease recognized, since every infected patient 
has an interest in knowing this fact, and its important bearing upon 
his or her relations to the uninfected. To every such patient, with 
the assurance that the disease is often benign and productive of little 
discomfort and in any case is curable, it should be stated that the 
affection is contagious and capable of transmission to sound persons 
by physical contacts of various characters. The patient should be 
instructed as to the nutritious character of the diet he should select, 
and should be informed that an increase in body-weight while sub- 
jected to treatment is decidedly favorable in the matter of prognosis; 
that the starving and sweating processes so highly esteemed by the 
charlatan and the advocate of the virtues of the waters of certain 
resorts are relics of antiquity, as useless in fact as they are frequent 
sources of peril. 

The bathing of the body is a matter of importance. Hot, Turk- 
ish, and Russian baths, as a rule, are to be interdicted, inasmuch as 
they tend to invite cutaneous hyperemia, and thus to favor the occur- 
rence of eruptions. Cool or tepid baths are to be employed sufficiently 
often for the purpose of cleanliness, and by the sponge rather than by 
immersion. Dry friction daily of the surface of the body may be 
ordered with advantage where the skin is still sound. The teeth, 
the mouth, and the gums require constant care. The use of the 
tooth-brush with cool water twice daily is a matter of importance, and 
the brushing should be preceded for a time, when the gums at the 
outset are in a tender, fungous, or hemorrhagic state, by gentle fric- 
tion with the finger, covered by a handkerchief dipped in a weak 
spirit-and-water lotion, to which tincture of cinchona and of myrrh 
may be added in any desired proportion. Tobacco in every form is 
decidedly injurious. Often the patient should be sent to a competent 

Traitement de la Syphilis. Paris, 1895. Les Chancres extra-genitanx. Paris, 
1897. Traite de la Syphilis, tome i. Paris, 1898-99. 

11 Therapeutique des Maladies veneriennes. Paris, 1876. 

12 Lecons sur les Malad. vener. Paris, 1883 and 1895. 

13 Syphilis. Vienna, 1896. 

14 Vorlesung iiber Pathol, u. Therap. d. Syphilis. Wiesbaden, 1896. 



698 NEW-GROWTHS. 

dentist for the extraction or the filling of carious teeth, and for the 
removal by the file or the dental engine of all sharp, projecting edges. 

Malt liquors, wines, and spirits should be employed solely under 
the explicit direction of the physician. They are exceedingly useful 
in debilitated subjects of a certain class, and need not be prohibited 
in toto to those long habituated to their use. At the same time, an 
improper use of these stimulants is in the highest degree harmful. 
When employed at all, they should be restricted rigidly to the dining- 
table and the hours of meals. 

A compliance with the laws of hygiene is even more requisite for 
the syphilitic than the non-infected. Fresh air, social amusements, 
exercise, the regular routine of business life, or, when this has proved 
exhausting, the recreation of travel — the claims of all these need at 
times to be urged by the physician. With this the patient should be 
encouraged to free his or her mind from needless anxiety, and to 
avoid particularly the company and conversation of those similarly 
infected, whose opinions are based too often upon ignorance or upon 
a knowledge of half-truths. The literature of syphilis, for a similar 
reason, is to be eschewed, as a mass of patients, too many of whom 
purchase treatises on the subject, are able only imperfectly to glean 
the meaning of the authors consulted. 

It should be a rule to urge a married patient to inform the con- 
jugal partner frankly of the fact of infection, for the sake of both. 
When this advice is followed much future trouble is avoided, and one 
of the obstacles to a completely favorable issue is at once set aside. 
Instances occur in which disruption of the conjugal bond results from 
infection of one, but usually of both parties ; it is a striking argu- 
ment, however, in favor of the policy here urged, that cases are rare 
in which a frank and honorable confession has been followed by 
separation. It may be added that in the " confessed " cases there is 
rarely subsequent infection of the innocent. The larger number of 
married patients are husbands. Recently infected young adults who 
have contracted a marriage-engagement should invariably claim re- 
lease from such a tie for the sake of all concerned. The syphilitic 
wet-nurse must at once be taken from the sound nursling, and the child 
with hereditary syphilis must be suckled only by its mother, who, 
according to Colles's law, the exceptions to which are so few as to 
prove the rule, always enjoys immunity against the diseased mouth 
of her own child. 

Respecting the medicaments employed in the treatment of syph- 
ilis, there is no routine plan which in every case can advantageously 
be followed. In no respect do physicians so differ from each other, 
judged by the standard of professional skill, as in their ability to 
use a single remedy with success. He who has the largest armamen- 
tarium is not always either the best equipped or the most successful. 
Mercury, iodine, iron, and quinine are the great remedial agents in 
syphilis, but they may vainly be used by one man in the long eifort 
to accomplish that which another speedily and brilliantly achieves by 
the use of the same remedies employed with greater skill. 



SYPHILIS. 699 

Of the other substances vaunted as either advantageous or specific 
in the treatment of the disease, no one possesses any claim whatever 
to the confidence of physicians. Sarsaparilla, dulcamara, stillingia, 
guaiacum, tayuya, mezereon, and the long list of other vegetable 
preparations whose virtues have thus been extolled, are for the most 
part as harmless in themselves as they are ineffectual for the relief 
of the malady. 

Before proceeding, however, to assume the responsibility of direct- 
ing a course of treatment for syphilis with remedies of acknowledged 
value, the physician will do well to remember that no two cases of the 
disease are precisely alike, and that there is the widest range between 
the most benignant forms encountered in private practice and the 
malignant cases seen in hospital-wards. Some forms of the malady 
are so mild as to constitute merely an inconvenience ; others are so 
severe as to destroy life. It is an axiom in venereal disease that more 
patients perish annually from blennorrhagia and its results than from 
syphilis. There could be no greater error than to treat by a uniform 
method any disease exhibiting so wide a variation in severity. 

Mercury, after the assaults upon it of generations of men of ad- 
mitted wisdom and candor, stands to-day unrivalled as a remedy for 
the relief particularly of those stages of syphilis in which the skin 
is involved. Administered with skill, it can be employed for years 
with advantage to the syphilitic patient, who, during a well-regu- 
lated mercurial course, should gain in weight, improve in vigor, and 
exhibit a healthy color of the skin. The sinking of the haemoglobin 
recognized by Justus 1 after a mercurial course is now known to be 
followed by a restoration to the normal level. No competent physi- 
cian to-day employs mercury in such a manner as to induce salivation 
or other toxic consequences. Such effects of the remedy result from 
carelessness or ignorance. In every discussion of the merits of mer- 
cury in syphilis both physicians and patients have been guilty of the 
ignorance or the folly of ascribing to the remedy the disastrous effect 
of the disease. 

Mercury may be given by the mouth, by inunction, by subcuta- 
neous injection, or externally by the aid of the vapor-bath. The most 
popular method, and that productive of least inconvenience to all 
concerned, is the method by ingestion. 

Ingestion". — In this mode of treating syphilis the mild chloride, 
bichloride, bicyanide, blue mass, or tannate of mercury may be em- 
ployed effectively. English practitioners as a rule prefer to all others 
the hydrargyrum cum creta, given in one grain (0.06) doses three 
times daily. These preparations, however, are rather less adapted 
than others for continued employment during long periods of time, 
and are open to the objection of either readily undergoing rearrange- 
ment into more stable compounds of the metal, or of producing unde- 
sirable irritative effects. With the protoiodide and the biniodide an 
impression can be produced upon the system that can readily be 

1 Int. Cong, of Derm., London, 1893, p. 1756. 



700 NEW-GBOWTHS. 

proportioned to the exigencies arising in every case, which can be 
sustained during that "chronic medication" which Fonrnier de- 
clares to be requisite in every chronic disease, and which can be 
exerted without fear of immediate or of remote deleterious conse- 
quences. 

Treatment of syphilis by the mercurial selected for use should, as 
a rule, be begun only at the moment of evolution of constitutional 
symptoms. The initial sclerosis of the disease is amenable to the 
action of the metal to a remarkable extent, but in a large proportion 
of cases the chancre will cicatrize, when in an ulcerative stage, with- 
out having recourse to general medication. Early mercurial medica- 
tion may well be reserved for snch primary lesions as are threatening 
in symptoms, and for such individuals as require or demand speedy 
cicatrization of their chancres, as, for example, those about to travel 
beyond the reach of medical assistance. Personal experience fully 
confirms the wisdom of the teaching which reserves specific medication 
until the second period of incubation has passed. ]STo local or general 
treatment can avert either a mild or a severe explosion of symptoms 
after that period is completed. In experiments made to determine 
this question of delay there has been either the production of strik- 
ingly irritative effects, such as a marked relapse, or unusual increase 
in the volume of the initial sclerosis immediately before the evolution 
of the first syphilodermata, or a distinct obstinacy in the latter to the 
action of the medicament employed. 

In the early stages of syphilis in adults the mercurous iodide may 
be named as one of the most trustworthy preparations. Of all classes 
of adult patients, including strong men and adult women, there are 
scarcely 2 per cent, who cannot take it, if the dose be proportioned to 
individual susceptibilitv. It is usuallv administered in pill or in 
tablet form in doses of i (0.01), i (0.013), ^ (0.016), or i (0.022) 
of a grain, three times daily, combined with the extract of gentian. 
The dose may be increased gradually according to the necessities of 
the case, from -J (0.033) to 3 (0.20), and even 4 (0.266) grains in 
the twenty-four hours. Many of the gelatin-coated pellets found in 
the market contain accurately divided doses of the salt. The sugar- 
coated pills of Gamier and Lamoureux, containing each 1 centi- 
gramme of the protoiodide, are efficient and largely employed. 

Beginning with a minimum dose, this remedy is to be steadily 
exhibited, and the daily quantity consumed to be gradually increased 
until the degree of tolerance of which the patient is capable has been 
ascertained. Should the stools become frequent, pain be excited, or a 
slight effect produced upon the mouth, as indicated by a metallic 
taste, moderate increase in the quantity of saliva, or any noticeable 
degree of tenderness of the gums, the dosage is to be gradually 
diminished until these symptoms disappear. Often the withdrawal 
of ^ (0.033) or i (0.013) of a grain daily will suffice to enable the 
patient to tolerate the quantity thus diminished. The medication is 
to be faithfully continued until the object in view is obtained, viz., 
relief of all symptoms of the disease. 



SYPHILIS. 701 

In the " tonic treatment of syphilis " the dosage is increased only 
on each third or fourth day, until irritative effects are produced, 
when, after an interval of two days, the quantity taken at the time of 
the production of such effects is reduced from one-half to one-third. 
This reduced quantity is termed the " tonic dose," and is thereafter 
continued throughout the treatment in " nearly all conditions of 
health or disease." 1 

No case of syphilis can be said to have been treated properly in 
which iron has not been given for at least a part of the time during 
which the patient was under observation. Ferric citrate with quinine 
is an excellent preparation administered at the meal-hours, in a small 
quantity of sound sherry wine ; or ferrous iodide may be employed 
in syrup, or in pills made after the formula of Blancard, or in Val- 
let's mass. In some cases tincture of ferric chloride may be em- 
ployed, but the physician should be careful about ordering an acid 
preparation during a mercurial course. There is no form of anaemia 
which responds more promptly to the chalybeates than does that pro- 
duced by the syphilitic virus. 

The mercuric iodide may be substituted for the mercurous iodide 
when, for any reason, it is thought desirable, beginning with a mini- 
mum dose of %4 grain (0.001), and increasing this gradually to 
y 4 o (0.0016), or rarely to V 2 o (0.0033), either in pill or in solution. 
The average dose of %o (0.0016) of a grain in pill-form, adminis- 
tered three times daily, soon after eating, is tolerated by the majority 
of all patients of both sexes without consciousness of unpleasant 
effects. 

Calomel may be administered in 1 or 2 grain doses (0.066-0.133) 
three times daily, in combination with an opiate to prevent its action 
on the bowels, or in /4o grain dose (0.0066) every hour. Small 
doses of blue mass or of gray powder may also be employed. The 
gray powder is most suitable for children and infants, but since the 
discovery in the drug of the corrosive chloride, either as of early or of 
late chemical production, the gray powder is esteemed less. The 
decimal trituration of calomel with sugar of milk is a far more suit- 
able compound. Corrosive sublimate, in doses of from %o (0.0033) 
to x /\2 (0.005) of a grain is exhibited in pill-form or in solution, and 
probably is employed more generally in the treatment of syphilis than 
any other mercurial salt. The objections to its use are suggested 
above. Though constantly employed in public charities, where it is 
furnished as a cheap and a convenient substitute for the more elegant 
preparations in the market, it is ordered much less frequently for 
syphilitic patients in private practice. When given in solution it 
produces a disagreeable metallic taste in the mouth that some patients 
can perceive after the lapse of hours. 

With many physicians of experience it is customary to employ 
opium, either alone or in connection with the use of mercury, for the 

1 Amer. Jour. Med. Sci., 1876, xcvii., p. 17; Phila. Med. Times, 1882, xii., 
p. 337. 



702 NEW-GEOWTHS. 

relief of ulcerative or other lesions of syphilis. Sometimes it is 
employed for the purpose of relieving pain, sometimes to prevent the 
cathartic action of the metal upon the Dowels, and again because it is 
supposed to possess some power of arrest over the destructive action 
of the disease. It should not, as a rule, be exhibited when by reduc- 
ing the mercurial or exchanging the latter for a ferruginous dose the 
same result can be reached. Few syphilitic patients are in the end 
brought to the desired termination of the disorder by the use of a 
remedy which interferes with assimilation and digestion. Temporary 
advantage often is gained by its employment, but this may be more 
than counteracted by its ultimate effect upon the gastro-intestinal 
tract. 

Inunction. — Mercury is introduced satisfactorily by the method 
of inunction. The metal when thus employed is absorbed readily by 
the system, and its therapeutic value is great. Inunction should be 
employed in every case which admits of it, since the gastro-intestinal 
tract thus is left undisturbed, and, further, the dose of any needed 
chalybeate or of potassium iodide by the mouth can be regulated with- 
out increasing or diminishing the quantity of mercury in daily use. 
Mercurial ointment compounded with lanolin is used best for this 
purpose. Cleanly but less efficient substitutes for it are provided 
in the oleate of mercury in the strength of 10, 15, or 20 per cent., and 
in the vasogen capsules. From -J to 1 drachm (2.-4.) of either the 
ointment, the vasogen compound (the mercury-vasogen capsules con- 
tain about 33 i per cent, of the metal) or the oleate may be rubbed 
into the skin at night before retiring, and the part selected for inunc- 
tion be cleansed by washing in the morning. Unna for this purpose 
praises the mercury-salve soaps. All these preparations, if continu- 
ally applied to a single portion of the skin, are liable to produce a 
mild local dermatitis, hence it is wise to select on successive evenings 
a fresh portion of integument for the local application, preferably 
that where the epidermis is relatively thin, as, for example, the 
flexor aspects of the joints. The patient can thus upon one evening 
anoint the inner faces of the thighs ; upon the next, the sides of the 
chest ; upon another, the loins, etc., taking care to avoid surfaces where 
an induced dermatitis is likely to prove especially annoying, such as 
the scrotum, the axillse, and the groins. The ointment in some cases 
may be well rubbed into the soles of the feet previously soaked in 
warm water, after which the socks or stockings may be drawn over the 
feet for the night. Often the ointment may be applied, as advised by 
Welander, spread on cotton, wool, or linen, and worn over a limb or 
the surface of the chest. In the case of infants the inunction is well 
performed by the natural movements of the child, if a flannel swath- 
ing-band previously smeared with the salve be wrapped about its 
belly, so that the mercurial preparation is kept in contact with the 
skin. Should local irritative effects be produced, these subside rapidly 
as a rule after a warm alkaline ablution followed with a bland dust- 
ing-powder. Subsequently or even before such accident in the case 



SYPHILIS. * 703 

of infants or of patients having unusually sensitive skins the mer- 
curial salve may be mixed with equal parts of lanolin, lard, or 
olive-oil. As some patients become disgusted with this routine, it is 
well at the onset to flavor the substance selected for inunction with 
lavender, rosemary, or bergamot. 

Too little attention has been attracted to the treatment of syphilis 
by mercurial inunction. With this fact in view the preceding para- 
graphs which describe the use of mercury by the mouth are to be 
understood as related in all cases to the employment of the metal 
by the skin. It is well to order inunction in all practicable cases ; 
to save the stomach as much as possible; to continue with the mer- 
curial ointment nightly, weekly, or less frequently, so long as there 
is a possibility of relapse; and to adjust carefully the quantity em- 
ployed to the exigencies of the case. In this manner patients may 
be relieved of all symptoms of the disease who have not during their 
treatment swallowed a dose of mercury, and the permanency of whose 
relief may be tested during years of subsequent observation. 

Fumigation. — One of the most effective methods of administer- 
ing mercury is by fumigation in the vapor-bath. It is employed by 
many experts as the sole means of exhibiting the mercurial selected 
for use, but it is, for the average patient, too inconvenient for contin- 
uous employment. It should regularly be ordered, first, in all cases 
in which the earliest syphilodermata are intense, generalized, and 
particularly conspicuous upon the face ; second, in all obstinate cases 
in which the patients are not women nor cachectic subjects of either 
sex ; third, at the outset of treatment of many " ignored " cases in 
which the syphilodermata, either more or less generalized, have pro- 
ceeded to uninterrupted evolution; fourth, in the severe cases of pa- 
tients coming from the country to the city, who are able to remain but 
a brief time within reach of advantages offered in metropolitan cen- 
tres. From \ to 1 drachm (2.-4.) of calomel, metallic mercury, the 
bisulphuret, the black oxide, or hydrargyrum cum creta may be em- 
ployed for each bath. It is common to order 1 scruple to 1 drachm 
(1.33-4.) each of calomel and cinnabar. The patient is stripped of 
his clothing and seated in a chair, the patient and chair being com- 
pletely enveloped in blankets, which are closely fastened at the neck of 
the bather. Beneath the chair is an alcohol lamp, surmounted by a 
metallic vessel containing water in ebullition, the hot vapor of which 
in a few moments induces copious perspiration. When this result 
is obtained the lamp is brought beneath a metal plate containing the 
substance to be volatilized. The patient remains exposed to the 
vapor about ten minutes after this process of sublimation is finished, 
and retires at once to bed without cleansing the skin, the fumiga- 
tion preferably being conducted before the hours of sleep. In the 
morning a bath may be taken for the purpose of cleanliness. It is 
convenient in the generation of the vapor in this way to make use of 
the Schering or other fumigating lamp, but the materials requisite 
for the production of all desired effects, with the exception of the 



704 NEW-GEOWTHS. 

alcohol lamp and the drug, can be procured of any skilful tinsmith. 
In the city male patients are often sent to bath-houses, where the fumi- 
gation is conducted in the daytime; and, as a consequence, they rarely 
experience unpleasant effects, such as are popularly associated with 
" taking cold " after exposure to the action of mercury. In most 
of these establishments provision is made that the head also can be 
exposed to the mercurial fumes, respiration being conducted through 
a tube in connection with pure air, a provision useful in certain 
cases of emergency ; and only " emergency cases " should be required 
to resort to fumigation of the head. 

Audry (cited by Pernet) has also employed mercury, by intro- 
duction of 40 per cent, suppositories of gray oil into the rectum. 

Subcutaneous Injection. — This method, which was first advo- 
cated by Scarenzio 1 in 1804 and popularized by Lewin, 2 has been ex- 
tended largely since its acceptance as a scientific procedure. 3 It is 
efficient and speedy, but will probably always find largest favor in the 
treatment of hospital patients, who are completely subject to the orders 
of their medical attendants. In common with some of the other meth- 
ods employed, injection provides for the exclusion of the medicament 
from the gastro-intestinal tract, and accomplishes the desired effect 
with a minimum and exactly mensurable dosage. The objection to 
its systematic employment outside of hospitals is the need of a phy- 
sician or an expert to administer the dose. The injection of mer- 
cury into the deep muscular tissue (the gluteus in its thickest part 
with the muscle wholly relaxed ; the trapezius above the upper scapu- 
lar angle with equal lack of tension), as well as when practiced more 
strictly hypodermatically, requires all antiseptic precautions both as 
to the point where the needle is inserted and as to the instrument 
itself. These injections occasionally have proved fatal (calomel, 
gray oil) ; grave mischief has followed in several instances from 
visceral troubles ; and the attacks of syncope which result in certain 
cases from these injections have presented alarming and even danger- 
ous features. 

The technique of mercurial injections is of importance. A syringe 
of the capacity of not less than 2 c. ctm. should be constructed wholly 
of glass and armed with irido-platinum needles. The operation is 
conducted with strict aseptic precautions, the patient, when intra- 
muscular injections are employed, preferably lying prone, though 
other postures are advised. The needle is plunged vertically into 
the deep part selected — post-trochanteric fossa (Smirnoff) ; inter- 
section of a horizontal line two finger-breadths above the great tro- 
chanter and of a vertical line separating the inner third of the buttock 
from the outer two thirds (Galliot) ; or, the middle of a line con- 

1 Trans. Int. Derm. Congress, London, p. 376. 

2 Die Behandlung der Syphilis mit subcutaner Sublimat-injection, Berlin, 1869; 
also translated by Proegler and Gale, Phila., 1872. 

3 Gottheil, W. S., Ten years experience in the treatment of syphilis by intra- 
muscular injections of insoluble mercurials. Jour, of Am. Med. Ass., 1907, xlix., 
p. 365. 



SYPHILIS. 705 

necting the anterior superior spinous process and the base of the 
coccyx. 

Corrosive sublimate, %2 (0.005) or Ys grain (0.008), dissolved in 
10 or 15 minims of distilled water may be injected at a time, the 
operation being repeated upon about twenty occasions. Bamberger, 
of Vienna, reported favorable results after the injection of an albu- 
minate or a peptone of mercury, thus attempting to avoid the danger 
of localized abscesses, and insuring speedy absorption of the metal. 
All formulae, however, proposed for preparation of solutions of this 
character have proved imperfect, both in consequence of failure to 
obtain a pure metallic albuminate, and also from lack of permanency 
in the solution. Staub's formula, the result of experiments made by 
Hepp, 1 may be taken as a sample of the rest : 

I£ Hydrarg. chlorid. corros., gr. xviij; 1|20 

Amnion, chlorid., gr. xviij ; 1 20 

Sod. chlorid., 3 j ; 4 

Aq. dest., f^iv; 120 M. 

Dissolve, filter, and add the white of one egg in distilled water sufficient 

to make Qv (120.) ; 15 minims of the solution contain about one- 
twelfth of a grain (0.005) of the sublimate. 

Hallopeau 2 and Scherwer 3 conclude that injections according to 
the method devised by Paul Salmon, of the anilarsinate of sodium 
("atoxyl") are equal if not superior to the action of the two chief 
remedies employed in the treatment of syphilis. He admits that 
treatment by these injections may be accompanied by intestinal pain, 
nausea, malaise, vomiting, and dysuria — conditions often requiring 
cessation of the treatment. Ten per cent, injections in the buttock, 
from 50 to 75 ctgms. at a dose are successively employed at intervals 
of from two to four days. Usually from five to eight injections suf- 
fice. Some seventy-five patients were thus treated at the St. Louis 
Hospital. Metchnikoff and Salmon believe that their experiments 
demonstrated the abortion of syphilis in monkeys thus treated. Puck- 
ner and Clark, 4 however, have shown that the recommended dosage 
of atoxyl is but one and one-half times as great as the advised dosage 
of arsenic in Fowler's solution though the claim has been made that 
it contains " forty times as much." 

Other preparations may be employed for hypodermatic injection. 
When insoluble salts of mercury are used they should be invari- 
ably warmed, carefully mixed by shaking, and a cream added. They 
include calomel in an average dose of 1 grain (.066) suspended in 
vaselin-oil, salt and water, or mucilage and water; metallic mercury, 
from 6 to 30 grains (.0.40-2) ; oleum cinereum; mercury with liquid 
vaselin or lanolin, 20 to 50 per cent. 0.05 to 0.1 at each injection; 
and the yellow and black oxides of mercury, and combinations of 

1 Traitement de la Syph. par les Inject, hypoderm. de Sublime. These de Paris, 
1872. 

2 Bev. Scientif. Paris, 1907, No. 24, 5 Ser., vii., p. 745. 
3 Wien. klin. Wochnschft., 1907, xx., No. 39. 
4 J. A. M. A., 1907, xlix., p. 1041. 
45 



706 NEW-GKOWTES. 

these with potassium iodide and other salts. Calomel, in combination 
with guaiacol, camphor, and oil, has been injected with a minimum 
of pain. 

The so-called antiseptic group includes salicylate of mercury. 
A Pravaz syringeful is injected every third day in the gluteal region 
beneath the muscular fascia?, of the following: 

IJ Hydrarg. salicylate, gr. xv-xxiv; 1|50 

Mucil. acac, gr. viij ; 1533 

Aq. dest., f^vss; 165| M. 

In this group are also included carbolate of mercury ; the thymo- 
late (10 per cent, suspensions in fluid paraffin) ; and the benzoate asso- 
ciated with sodium chloride, 2 parts, and cocaine hydrochlorate, 1 
part, in 500 of water. 

The amide group includes mercuric formamidate, 1 per cent, solu- 
tion ; glycocoll of mercury, alaninate of mercury, and succinamide of 
mercury, the last two in 1 per cent, solutions. 

Beside these mercurial preparations, potassium iodide and iodo- 
form have been injected subcutaneously in a few instances, it is 
claimed with advantage. 

Intravenous injections of mercury in syphilis were introduced 
by Baccelli in 1893, but, according to Marshall, have not been shown 
to possess any advantages over other methods employed. Chopping, 
however, had satisfactory results in twenty-three days after intro- 
duction into artificially distended veins, of 20 minims of a 1 per 
cent, solution of mercurous cyanide; Pernet 1 states that the method 
is especially effective in syphilitic diseases of the eye. Lydston 2 
believes that in 48 hours a patient may be brought completely under 
the influence of mercury by intravenous injections (15 to 25 minims 
of a 2 per cent, solution of the bichloride of mercury). Ten cases 
are reported improved. The median basilic or median cephalic 
vein in the forearm was selected, care being taken to place the dosage 
fully within the lumen of the vein and to remove the tourniquet be- 
fore the discharge of the mercurial solution from the syringe. 

Ptyalism, stomatitis, fetor of the breath, or a fungous condition 
of the gums with inappetence and other characteristic symptoms of 
the ill effects of mercury, including all grades of gastro-intestinal 
disturbance, are seen rarely in modern practice, and they should 
never occur in a properly regulated mercurial course. When they 
are produced, the tongue projected from the mouth is usually tumid, 
and exhibits at its lateral borders the imprints of the inner facesi 
of the molar teeth. Its surface is also covered in various degrees 
with a thin, dirty-grayish coat; and the odor of the breath is pecu- 
liarly offensive, being often noticeable at a distance of several feet 
from the patient. In such cases the food should be liquid and nutri- 
tious, both hot and cold drinks should scrupulously be avoided, and 

*:Brit. Med. Jour., Nov. 30, 1897. 
2 J. A. M. A., 1907, xlix., p. 1662. 



SYPHILIS. 707 

the mouth frequently be cleansed with washes containing dilute 
liquor sodse chlorinate, potassium chlorate, or a weak solution of car- 
bolic acid. In particularly severe cases, potassium chlorate may be 
employed to the extent of 1 drachm (4.) daily. The compressed tab- 
lets of this salt, each containing 5 grains (0.33), may be slowly dis- 
solved in the mouth. The mercurial is to be suspended in all cases, 
and iced water is to be interdicted, gangrene having followed its use 
in a few cases. In milder forms tincture of myrrh and of cinchona, 
diluted with sweetened water, or honey and water, will be sufficient 
for local medication of the mouth. 

Iodine. — Iodine in pill form in doses of %4 of a grain (.002) is 
of great value as a remedy in syphilis. The drug is, however, em- 
ployed chiefly in the salts of potassium and sodium. The iodides of 
ammonium, rubidium, and strontium are less effective. Todipin 
(Merck) and lipiodol (Lafay) are iodinized oils, and are employed 
both by the mouth and by injection. 

Iodine possesses some value, without question, in every stage of 
syphilis, and is, therefore, indiscriminately used by many practition- 
ers. Its value, however, in so-called " late secondary " and " tertiary 
stages " is incontestably greater than in the earlier lesions of the dis- 
ease, and its use should largely be restricted to the particular periods 
in which these manifestations appear. Every prudent physician will 
hesitate before ordering for a disease exhibiting cutaneous lesions a 
remedy which will positively produce such lesions in the majority 
of all patients ingesting it. In this connection the reader will do 
well to consult the chapter on Dermatitis Medicamentosa, in which 
the various eruptions produced by this drug are recorded. Thought- 
ful men are beginning to inquire, in the light of the present knowl- 
edge upon this subject, to what extent the syphilodermata have in the 
past been aggravated or obscured by this remedy. He would indeed 
be bold who should attempt to prove that the medicamentous erup- 
tions thus excited have not, in the past, figured largely in the cata- 
logue of the syphilodermata. 

The value of the iodine compounds, nevertheless, properly ad- 
justed to the age and other conditions of the disease, is incontestable. 
Whether given alone or by the so-called " mixed " treatment in com- 
bination with mercury, or administered internally • while a mer- 
curial is introduced by the skin, or exhibited by alternation with 
the metal, in each these compounds find a special value, and may 
simply be indispensable. Potassium iodide may be given in doses of 
from 5. grains (0.33) to 1-2 drachms (4.-8.), well diluted with water 
(a gobletful preferably), three or four times daily one hour after 
eating. The larger doses should invariably be reached gradually; 
they should never be employed except by special order of the phy- 
sician, and when the patient is within easy reach of the latter ; and 
they should always be ordered with the understanding that the patient 
shall diminish or suspend treatment in case of unpleasant results. 
When the remedy produces gastric distress, it is administered often 



708 NEW-GBOJVTHS. 

in connection with pepsine, pancreatine, or taka-cliastase. Often the 
dose is tolerated well when given in a glassful of milk. 

Symptoms of iodism other than the production of cutaneous 
lesions, such as coryza, oedema of the eyelids, abdominal tension and 
tenderness, and faucial irritation, are often the result of the first few 
doses of iodine ingested, and these symptoms may bear no relation to 
the size of the dose. In certain cases, 1 or 2 grains (0.066-0.133) 
will be sufficient to produce the most disagreeable effects, which, if 
they occur before the remedy be suspended, may not return with even 
the largest doses. In a few cases potassium iodide produces violent 
toxic effects in any dose, owing to exceptional idiosyncrasy. Both 
ammonium chloride and ammonium carbonate are recommended for 
use in combination with potassium iodide, as increasing its efficiency. 
Sodium, ammonium, and lithium iodides possess also, without ques- 
tion, some influence over the disease, but they are for most cases less 
efficacious than the potassium salt. Of the three iodides named, 
lithium iodide is apparently most prompt in its effects. 

Potassium iodide is employed frequently in the well-known " sirop 
de Gibert," which though first popularized in the Saint-Louis Hos- 
pital, in Paris, has since been employed extensively in the United 
States. It has slightly been modified to suit the varying tastes of 
many surgeons. It is ordered in the following formula: 



IJ Hydrargyri biniodid., 




gr. ss-ij; 


|.033-0.133 


Potass, iodid., 




5ij-viij ; 


8-30 1 


Gentian, syrup, (vel 1 








syrup, glycyrrhiz.), v 




aa fjij; 


aa 601 


Aq. dest., j 






| M. 


Dose. A tablespoonful in water, 


after 


eating. 





The syrup of licorice disguises the taste of the drug better than 
most of the other syrups used. With the dosage carefully regulated, 
a few drops (1 to 15) may be administered with advantage to 
children. 

The following are indications for the use of potassium iodide 
either alone or by the so-called " mixed " method in the treatment of 
syphilodermata : the occurrence (1) of tubercular, gummatous, or 
ulcerative lesions; (2) of formidable, nervous, visceral, or other 
non-cutaneous symptoms with early or late, mild or severe syphiloder- 
mata, as, for example, grave ulcerations of the velum or the fauces 
with a symmetrical macular eruption, or coincidence of a generalized 
pustular or a papular syphiloderm with hemiplegic, aphasic, ocular, 
or renal complications; (3) of manifestations which either assume 
the so-called " galloping " type, being succeeded rapidly by more and 
more formidable symptoms, or which exhibit the capriciousness of the 
disease in a reversal of the usual sequence of evolution, as, for exam- 
ple, when symptoms commonly described as " late " phenomena occur 
within a few weeks after infection and are followed by the early sym- 
metrical rashes ; (4) of early or late symptoms occurring in cachectic, 
strumous, or otherwise debilitated patients. Mercury is assuredly 
not a tonic in tuberculosis commingled with syphilis. 



SYPHILIS. 709 

Prophylactic treatment of the initial lesion of syphilis, with a view 
to the exclusion of systemic infection, has been made the subject of 
experimentation by Metchnikoff and Roux, who practiced a more or 
less prolonged inunction at the site of the inoculation with an oint- 
ment composed of one part of calomel and two of lanoline. The re- 
ports of successes thus obtained in animals, and in one instance in 
the human subject, are offset by a record of some failures, but a 
sufficient probability has been established to justify the employment 
of this measure in available cases. 

Local Treatment. — The local treatment of the initial sclerosis of 
syphilis by complete excision, lauded by Auspitz, has been practised 
(since the date of his paper in 1879) by Kolliker, Zeissl, Leloir, 
Chadzynski, Mauriac, and others. 1 The result has proved conclu- 
sively that such operative interference furnishes no bar to constitu- 
tional infection. Simultaneous extirpation of all lymphatic glands 
in the vicinity of an initial sclerosis, with ablation of the latter and 
a mass of tissue about it, have repeatedly proved unavailing to pre- 
vent the occurrence of systemic infection. Chancres should not be 
destroyed bv caustic agents of any character, as the caustics are liable 
to induce either irritative or inflammatory effects which may be fol- 
lowed by denser induration. Ointments, as a rule, are also objec- 
tionable, exception being made in the case of hemorrhagic lesions 
when the removal of an adherent dressing is followed by unpleasant 
consequences. Cleanliness with soap and water is of chief impor- 
tance. There are few better local applications at this period of the 
disease than painting with a saturated aqueous solution of pyok- 
tanin-blue. The parts may then be dusted with a dry powder, such 
as europhen, iodol, zinc stearate, calomel, hydro-naphtol, or boric 
acid; or be dressed with a piece of soft lint, saturated in pure or 
dilute lotio nigra, or, even better, a spirit-lotion containing tannin 
and carbolic or boric acid. Opiated washes or iodoform (which is an 
anaesthetic for many ulcerative surfaces) may be requisite in painful 
and ulcerative lesions. 

When a primary venereal sore of any character (the initial scle- 
rosis of syphilis or the chancroid) becomes phagedenic or gangrenous,. 
or, even in the absence of both these calamities, extends rapidly in 
depth or superficial area, cauterization should not be practised. The 
most effectual treatment of these complications in the genital region 
is by the employment of the continuous hot water-bath, aided by 
asepsis. The patient remains seated in the bath (the water being 
of the temperature most grateful to the affected surface and with great 
care maintained at that degree of heat) throughout the day, or, in 
formidable emergencies, if carefully watched, by day and night. 
The bath is left by the patient only for the purpose of evacuating the 
bladder or the rectum. Granulation and repair gradually ensue. 
Whenever the patient leaves the water the parts are dusted with 
iodoform or with iodol. By this invaluable means, in both hospital 

1 See Keyes' later communication on this subject, loc. cit. 



710 NEW-GEOWTHS. 

and private practice, cicatrization of extensive ulcers which extend 
from the genital to the pubic region may be secured. 

Local treatment of the syphilodermata may be demanded either 
by reason of their appearance on exposed surfaces, as on the face 
and the hands, or by reason of their obstinacy or threatening char- 
acter, as when they are rapidly ulcerating. Macular and papular 
lesions of the face may be treated by local applications of mercury : 
5 per cent, oleate; mercurial ointment, 1 to 2 drachms (4.-8.) to the 
ounce (30.) of cold-cream salve or of vaselin; red oxide, from 2 to 4 
grains (0.133-0.266) to the ounce (30.) ; or ammonium chloride, | to 
1 scruple (0.66-1.33) to the ounce (30.) of ointment. Lotions of 
bichloride, 1 to 2 grains (0.06-0.133 to the ounce (30.)) of cologne, 
are also efficient. These preparations are more effective if applied 
at night, and left upon the lesions during the hours of sleep, and each 
is preceded best by hot bathing of the surface for several minutes, as 
in the preparatory treatment of acne papulosa. The sulphur prepar- 
ations employed for the relief of that disease will at times be foimd 
useful also in the local treatment of the syphilodermata. 

Hot ablution is particularly useful in the treatment of the scaling 
and frequently fissured lesions of the palms and soles, the pain of 
the local symptoms in severe cases being greatly alleviated by this 
treatment. After the epidermis in these parts has been well macer- 
ated, the hands or the feet should thoroughly be dried, and the mer- 
curial, tarry, or other salve be well rubbed in. The medicated mulls 
and plasters are here of value. A glove or a stocking should then be 
drawn over the part. 

Secreting condylomata, flat papules, vegetations, etc., also require 
bathing with soap and water, especially when situated at the mucous 
outlets of the body or on the scalp. When the secretion is offensive 
in odor, formalin, boric or carbolic acid, thymol, or chlorinated 
soda should be added to the lotion. Cleanliness, indeed, is more 
essential to the syphilitic patient, man or woman, than to the healthy. 
After the cleansing or disinfecting ablution the parts may require 
pencilling with the crayon or with solutions of silver nitrate, 10 to 
20 grains to the ounce (0.50-1.5), and may be dressed with a powder, 
such as dry calomel, europhen, iodoform, iodol, hydro-naphtol, bis- 
muth subnitrate, zinc oxide, sodium salicylate, or starch. Vegetat- 
ing lesions of these regions may require also pencilling with a crayon 
of silver nitrate. Ointments, as containing grease, are decidedly 
objectionable local applications. 

Crusted and ulcerative lesions, large or small, are to be treated in 
accordance with general principles. Crusts should always be re- 
moved either by the oil and soap-and-water treatment, or with a der- 
mal curette, after which removal the underlying ulcers should be 
cleansed thoroughly, pencilled with silver nitrate, filled with pow- 
dered boric acid, iodoform, iodol, or calomel, or touched with a 5 to 
20 per cent, solution of carbolic acid, and then be dressed with a 
dilute ointment of mercuric nitrate, 1 to 2 drachms (4.-8.) to the 



SYPHILIS. 711 

ounce (30.). Large syphilitic ulcers are often encountered on the 
surface of the lower extremities, and in this situation elastic com- 
pression by a rubber bandage will greatly accelerate their cicatriza- 
tion. 

Ointments of ammoniated mercury, blue ointment, compound 
iodine ointment, and those containing the yellow oxide are useful in 
many cases. The mercurial, salicylated, zinc-oxide, and other plas- 
ters often are required for infiltrations. 

The syphilodermata are in general amenable to the action of the 
mercurial vapor-bath, which exerts upon them both a local and a con- 
stitutional influence. Those affecting the face are benefited thus by 
exposure to the metallic vapor in the " head-piece " arrangement 
already described. The patient also may avail himself less comforta- 
bly of the same local treatment by holding the breath and exposing 
the head and face for a few minutes at a time to the fumes of the 
mercury beneath the blanket, in the plan described as practicable at 
the bedside. 

The syphilodermata, if treated locally by the measures described 
as useful in non-syphilitic cutaneous affections of similar type, will 
commonly proceed to a satisfactory involution if the general treat- 
ment be skillfully ordered. 

The local treatment of syphilitic lesions of the mucous surfaces is 
both hygienic and medicinal. Catarrhal conditions of adjacent 
mucous surfaces (vagina, nasal cavity) require attention. The parts 
should be kept free from all irritation (tobacco in all forms, iced and 
hot articles of food and drink, condiments, acetous and alcoholic 
fluids in the mouth ; coitus and irritating injections of vulva ; napkins 
that have been soiled over the ano-genital regions of infants). 
Locally, the silver-nitrate crayon, used as a pencil, is effective in the 
management of moist patches, applied once daily or every second or 
third day. Occasionally stronger caustics are required, such as mer- 
curic nitrate or nitric acid. Mouth-washes containing potassium 
chlorate, myrrh, and honey; 15 to 20 drops in water of Bellamy's 
iodized phenol ; milk of magnesia ; very dilute lotions of tincture of 
ferric chloride; or dilute muriatic acid, a teaspoonful to a pint of 
sweetened water; and carbolated washes, are required in different 
cases. In very great soreness and tenderness of the mouth only 
the blandest applications are tolerated, such as thin flaxseed-tea, 
oatmeal-gruel as a wash, and gum-acacia water. A few formulae 
are appended: 

]J Potass, chlorat., 3j; 4| 

Mel. depurat., 1 -- - . 15| 

Myrrh, tinct., / aa 3 SS > li3 \ 

Aq. dest., ad ^v j ; ad 180 1 M. 

Sig. A teaspoonful in water as a wash for the mouth and throat. - 

$ Acid carbolic, 3j; 4| 

SSffe*,} »*■; 552 i 

Spts. vin. rectif., 3i j ; 81 

Aq. dest., ad f I j ; ad 30| M. 

Sig. Fifteen to twenty drops as a lotion in water, for the mouth. 



712 NEW-GEOTVTHS. 

$ Potass, chlorat., 3j; 4| 

Aq. menth. piperit., aa 3VJ ; aa 180| M. 

Sig. Gargle and wash for the mouth; to be used slightly diluted. 

The internal management of these cases is that demanded by the 
general condition of the system and the stage of the disease, as ex- 
plained in the concluding pages of this section. 

The treatment of inherited is mainly that of acquired syphilis 
with such modifications as are required by the tender age of the sub- 
ject of the disease and by the special characters of the eruptive and 
other symptoms in the infant and child. The mother who is demon- 
strably the subject of the disease requires antisyphilitic treatment dur- 
ing any pregnancy where there is possibility of taint of the product 
of conception, irrespective of the presence or absence of maternal 
symptoms; this is especially important in pregnancies succeeding 
those terminating either in abortion or the birth of a syphilitic child. 
The infant born of a syphilitic mother or luetic parents should be 
spared specific medication until evidences of infection are presented, 
seeing that in some cases the foetus and newborn infant escape even 
when lues is made probable by the antecedents of the progenitors. 
The syphilitic child when the disease is inherited should be kept at 
the breast of the mother and not be suckled by any other woman. All 
syphilitic infants require special provision for their nutrition; cod- 
liver oil generally is indicated. Inunction is to be practised by 
anointing the swathing-band with a strong or modified mercurial 
salve, the motions of the child being in general sufficient to insure a 
proper medication by introduction of the medicament. As the skin 
of the abdominal surface in these young patients is generally sensitive, 
care should be taken to suspend the application of the unguent and 
to apply a dusting-powder until any resulting dermatitis is relieved. 

Internally, calomel or the gray powder, to" °f a grain to 1 grain 
(0.006 to 0.06), may be applied to the tongue after trituration with 
the sugar of milk. The stronger homoeopathic triturations are use- 
ful for this purpose. We rarely employ the bichloride of mercury for 
infants, as the other preparations of the metal are commonly efficient 
and better tolerated. The salts of iodine are less valuable in inher- 
ited than in acquired syphilis, but when indicated the potassium salt 
may be given in doses of from tV to 2 or 4 grains (0.006 to 0.133 or 
0.266), administered in solution three times daily or oftener when 
required. Iron is indicated generally, and in particular the iodide 
of iron, which may be given in the form of syrup 2 to 5 drops in so- 
lution. The dosage is to be varied with the age and vigor of the 
child. Lesions of the mucous surfaces (mouth, anus, nares) require 
special hygienic care, and the use of lotions of boric acid, formalin, 
chlorinated soda, and, in especial, soap and water is desirable. These 
should be followed often, particularly about the ano-genital region, 
with the application of dusting powders. The eruptive symptoms in 
inherited syphilis are to be treated like those in the acquired disease, 
due care being taken to protect the tender skin from irritation. The 



CHANCROID. 713 

tars and stronger mercurial salves should not be employed over the 
skins of very young infants. 

Prognosis^ — The prognosis of syphilis is in general favorable, 
popular opinion on the subject being at variance with fact. Benig- 
nant syphilis may disappear without treatment. 

Malignant forms of the disease may, but rarely do, destroy life. 
The element of treatment, both as to its character and the period of 
its continuance, enters more largely into the estimate upon which a 
prognosis rests than it does in most other disorders exhibiting cuta- 
neous symptoms. The syphilis untreated, whether because of failure 
to recognize its character, or of ignorance, poverty, neglect, or dissipa- 
tion, is usually grave. The same may be said of syphilis occurring 
in strumous, tuberculous, and cachectic subjects, and in those en- 
feebled by age, by other diseases, by chronic alcoholism, or by sexual 
excesses. Hereditary syphilis is by far the gravest form, not merely 
because of the tender age of its victims, but also because at the earliest 
period of existence they are burdened with a disease which may first 
attack organs essential to life. 

The majority of adult white patients, with hygienic environment, 
sooner or later recover from the acquired disease, marry, and beget 
in the end sound children. 

CHANCROID. 

This term has been adopted generally in America and England 
for the purpose of designating the virulent, local, contagious ulcer of 
the genitals, designated also as the " simple," the " soft," or the " non- 
infecting" chancre, the chancrelle of French authors. Chancroid 
has no relation to syphilis, nor to the neoplasmata with which syphilis 
is commonly classified, though, it is important to note, it may precede, 
accompany, or follow the initial lesion of that disease. As it is, how- 
ever, an affection with which the initial sclerosis of syphilis may be 
confounded, and is also not merely a venereal lesion, but one which 
may be encountered upon the skin as well as upon mucous surfaces, 
it is briefly described in this connection. 

Chancroids present as distinct a uniformity of feature as the 
lesions of vaccinia or of herpes zoster. They are thus stamped with 
special and readily recognized characteristics, differing in this re- 
spect from the various modes in which the first lesion of syphilis may 
declare its nature. The virus, for such it must be termed, of the 
disease is one sui generis, and derived exclusively from lesions of like 
character. This virus, which is contained in a purulent secretion, is 
capable of transmission by inoculation and auto-inoculation. After 
such successful inoculation there is no period of incubation. The 
results of experimental generation of the virus in human subjects in- 
dicate that the pathological process which it awakens can be deter- 
mined within twenty-four hours after its introduction within the 
skin. At times, after accidental infection, eight or ten days elapse 
before the lesion of the disease is manifested, cases presumably in 



714 NEW-GEOWTES. 

which the virulent secretion has remained pocketed in the orifice of 
a follicle or in a fold of mucous membrane, where its irritant effects 
have finally opened an avenue for its deeper ingress. When typically 
developed the chancroid is seen to be a pustular lesion, frequently 
multiple, of roundish outline, beginning as a pinhead-sized, turbid 
vesico-pustule, rapidly enlarging to a pea- or bean-sized, well-devel- 
oped, projecting, yellowish, globoid elevation of the epidermis, filled 
with greenish-yellow pus. When located in furrows or depressions 
of the surface it may have a linear, oval, or even a dumb-bell shape, 
the latter in consequence of extension from a sulcus to overlying folds. 
Clinically the roof-wall of this pustule is not frequently encountered, 
the objective symptoms being the ulcers which represent the floors of 
separate lesions. These ulcers vary with the shape of the superim- 
posed pustules, being round, ovoid, or linear, occasionally irregular 
in outline, with sharply defined or cut edges; they have an uneven, 
pus-bathed floor ; a faint pinkish areola ; a supple, non-indurated base ; 
an abundant puriform secretion ; and are accompanied or unaccom- 
panied by pain, according to the degree of inflammation present. In 
consequence of the auto-inoculability of the discharge these ulcers 
frequently give rise to others in the vicinity, as when the prepuce 
lies in contact with chancroids of the glans. 

The ulcers thus presented usually attain an average size of that of 
a pea or of a bean in the course of from ten to fourteen days ; they 
then remain in an indolent and suppurative condition, showing no 
tendency to heal for a fortnight or three weeks; and finally they 
granulate, exhibiting the ordinary phases of repair. The resulting 
cicatrix is either transitory or, more often, indelible. In exceptional 
cases the ulcer spreads widely. In the groin it may attain a diameter 
of several inches; its floor secreting scantily; its edges lurid, under- 
mined, purplish, or ragged ; its color reddish, bluish, purplish, or 
leaden. Fistulous tracts and sinuses, filled with an ichorous sero-pus 
radiate in dependent situations ; the base of the sore is densely indu- 
rated; its career may be prolonged for years, and induce finally a 
systemic cachexia not different from that seen in all chronic ulcera- 
tions of severe grade. In other cases the occurrence of gangrene, or 
phagedena, changes the features of the lesion to those of other ulcers 
undergoing similar metamorphosis. 

Chancroids may occur upon any exposed mucous surface of the 
genitalia of both sexes, upon the integument of the penis, scrotum, 
labia, thighs, fingers, perineum, peri-anal region, and, very rarely 
indeed, upon the face. In consequence of their tendency to relapse, 
their abundant contagious secretion, and their auto-inoculability, 
chancroids are more frequently encountered than is the primary syph- 
ilitic lesion among the filthy, the poor, and the classes that frequent 
hospitals and dispensaries. Among the wealthy, the well-to-do, and 
the cleanly this order of frequency is reversed. 

The chancroid ulcer is also much more frequently complicated 
by surgical accidents than is the infecting lesion of syphilis. This 



CHANCROID. 715 

result is partly due to the prevalence of an ulcerative type in all its 
manifestations, and in part to its situation. Thus, the ulcer is often 
accompanied by severe inflammatory symptoms, which may be aggrav- 
ated both by phimosis and paraphimosis, occurring with stenosis of 
the preputial aperture, or with a long, lax, and redundant foreskin. 
Phagedena is also a formidable complication, whether of sloughing 
or of serpiginous tendency, the lesion in each case losing its chan- 
crous characteristics. It is evident also that the disease may coexist 
with others of a different character. Thus, a single point may simul- 
taneously be . inoculated with chancroidal and syphilitic virus ; the 
former, without an incubative period, followed rapidly by a pustular 
or an ulcerative lesion; the latter, after its incubation is complete, 
producing the characteristic symptoms of an initial sclerosis. Chan- 
croids may also be found coexisting with various early and late syph- 
ilitic lesions of the genitals, with vegetations, with blennorrhagic dis- 
charges and balanitis, with pediculi of the pubes, and with herpes 
progenitalis. Patients of the class exhibiting these lesions not infre- 
quently present themselves at public dispensaries with three or more 
of these concurrent disorders. 

One of the most serious complications of the chancroid is its asso- 
ciation with a specific lymphangitis, periadenitis, or adenopathy. In 
this case the lymphatic trunks connected with the lesion become in- 
flamed, indurated, and irregularly corded, with the overlying in- 
tegument often cedematous, reddened, and painful. The infective 
process in these vessels rarely terminates by suppuration. The bubo 
of chancroid is more common, and this adenopathy may be either 
sympathetic, resulting from the severity of the process at the site of 
the lesion, or be virulent, due to the transmission of an inoculable tox- 
ine to one or more of the glands in near connection with the source of 
the trouble. These different gland-complications may coexist in one 
person, in men more often than in women, and in about one of each 
four or five cases presented to observation. When inoculable pus has 
been formed in a neighboring gland the latter is at once converted into 
the seat of an abscess, the pus of which, whether evacuated spontane- 
ously or by the knife of the surgeon, speedily inoculates the lips of the 
wound through which exit has occurred. The wound and contiguous 
abscess-cavity then form a large chancroidal ulcer, usually inguinal 
in situation, as the glands in this locality are nearest the most fre- 
quent seat of the lesion. Such an inguinal ulcer discharges a greenish- 
yellow pus often commingled with blood ; its borders are undermined, 
thin, livid or purplish, and ragged; its floor is irregular, sloughy, 
and often covered with nodules representing the debris of glandular 
structure ; from it depart sinuses traversing the tissues in the vicinity, 
often downward to the thigh, occasionally upward over the belly. 
When occurring in strumous and cachectic subjects, or when long 
neglected or mismanaged, the resulting disorder is of serious charac- 
ter, and it may surpass in duration and severity certain of the varie- 
ties of lupus and epithelioma. 



/16 NEW-GROWTHS. 

These facts have an important bearing. It is true that syphilis 
is a constitutional disease, and that it usually occurs but once in a 
lifetime. It is equally true that the chancroid is evidence of a local 
and non-systemic disorder, producing only such constitutional effects 
as may all other local affections of chronic course and severe grade ; 
but it is an error to suppose for these reasons that the chancroid is 
the milder of the two maladies. Many of its consequences are much 
more severe, and some of them even more malignant, than the average 
of syphilitic sequels, and even, as indicated above, are worse than 
some forms of other diseases usually classed as malignant. Greater 
attention should be generally directed to the truth respecting the com- 
parative gravity of the two diseases, as there is widespread ignor- 
ance of the facts. 

Pathology. — The pathology of the chancroid, has been illustrated 
by the researches of Biesiadecki, Auspitz, and Unna. The micro-or- 
ganisms discovered in all coccogenous lesions are usually abundant 
and readily demonstrable. Those first described by Ducrey, of 
iSTaples, 1 recognized now as the effective agents in the produc- 
tion of the disease 2 are short, thick strepto-bacilli measuring 1.46 
by 0.50 fji. These observations were confirmed by Krefting, of Chris- 
tiania; 3 while the bacilli discovered and claimed as pathogenic by 
Unna (his observations being later confirmed by Quinquaud and 
Xicolle) occur in the form of twisted coils and chains, measuring 
1.25 by 0.33 fi. 

Anatomically, there is disclosed by the microscope a uniform, 
dense infiltration of the corium with elements which undoubtedly 
represent inflammatory metamorphosis of the connective tissue of the 
derma ; degenerative changes where the ulceration has proceeded su- 
perficially ; enlargement of vessels from thickening of their walls, often 
with diminished lumen ; and relatively intact rete and corium at the 
lateral borders of the ulcer. This fully confirms the inferences sug- 
gested by a clinical study of the disease. Many roundish circum- 
scribed, clean-cut ulcers with purulent floors occur upon the skin 
that bear no relation to the chancroid disease. It is the history and 
career of the disease that stamp it with an individuality of its own. 
It is not the form and appearance of its pus-elements, but their power 
and potency, which make them singular. 

Diagnosis. — Chancroid is to be distinguished from syphilitic 
chancre, but no skill, however great, and no experience, however wide, 
will enable the diagnostician, even when typical chancroid is present, 
to assert that syphilis will not follow, until the longest incubative 
period of the initial sclerosis of the last-named disease has elapsed 

1 Congres internat. de Derm, et de Syph., Paris, 1889, p. 229. 

- Culture and inoculation experiments conclusive as to the agency of the Ducrey 
bacillus have been made by Istamavaff and Askpeonz, Jahresbericht d. Path.- 
Microog., 1898, xiv. ; Davis, Jour, of Med. Research, 1904, ix. ; p. 401; Lancret, 
Bull. Med., 1898, xii., p. 1051, and Temosczewski, Zeit. f. Hyg. u. Infect., 1903, 
xiii., p. 327. (Keyes.) 

"Archiv, 1892," xxiv., p. 41. 



CHANCROID. 717 

without production of suspicious symptoms. The rule which neces- 
sarily follows is imperative, and, being too frequently ignored, bitter 
disappointment on the part of the infected individual, and mortifi- 
cation on the part of the physician, have naturally resulted. No pa- 
tient suffering from a chancroid can he promised immunity against 
syphilis until two and a half months have elapsed after the date of 
last exposure. Subject to this essential reserve, the diagnosis rests 
upon the pustular, ulcerative, and discharging features of the chan- 
croid, its failure to indurate at the base, its auto-inocul ability, its 
appearance without previous incubation, its more formidable localized 
expression of disease, and the characteristics of the accompanying 
adenopathy. The short-lived, superficial vesicles of herpes progen- 
italis, often accompanied by tingling and painful sensations, with 
sequels in the form of equally superficial, epidermal excoriations, are 
not to be confounded with chancroids; yet it must be remembered 
that these lesions may also precede or may accompany any form 
of venereal disorder. Chancroids are to be distinguished also from 
early and late symptoms of syphilis developed in the genital region 
and from non-syphilitic vegetations and molluscum epitheliale having 
the same localization. 

Treatment. — The most effective and ultimately the most satisfac- 
tory treatment of chancroids is by asepsis patiently carried out. Less 
satisfactory is the routine treatment by destructive cauterization with 
either nitric or sulphuric acid now practically abandoned by the 
ablest practitioners. Keyes recommends a previous application of 
pure carbolic acid, in order to benumb the part and thus render 
the subsequent application less painful. If employed at all, the car- 
bolic acid should carefully be wiped from the sore before the subse- 
quent cauterization, as the two acids will explode if suddenly brought 
in contact. As the slough separates the ulcer may be dressed in ac- 
cordance with the general principles governing the treatment of sim- 
ple granulating wounds. Special care should be taken by all prac- 
ticable measures to avoid the possibilities of auto-infection. Vinous, 
carbolated, and opiated lotions, painting with a saturated aqueous 
solution of pyoktanin-blue, powders of boric acid, iodoform, iodol, 
calomel, bismuth subnitrate, and starch, simple unguents, and the in- 
terposition of a pledget of borated cotton between all affected and 
sound tissues — these measures in most cases suffice to insure relief. 
Pencillings with silver nitrate, though ineffective for the purposes of 
cauterization, often answer a good purpose in hastening repair. The 
prepuce may require division or circumcision. 

For grave and extensive ulcerations, accompanied or unaccom- 
panied by phagedsena or by gangrene, there is no treatment compar- 
able in value with the hot water-bath of an average temperature of 
98° F. For the details of this method the reader is referred to the 
paragraph devoted to the treatment of syphilitic chancre. 

Phimosis and paraphimosis, when complicating chancroids, re- 
quire the surgical treatment appropriate for the relief of those con- 



718 NEW-GEOWTES. 

ditions. For the accompanying, adenopathy in chancroid disease, be- 
fore suppuration has occurred, rest is essential, with laxatives and 
gentle local compression. When there are great heat and tenderness 
a few leeches may be applied. After pus has formed it may be 
evacuated with an aspirator-needle, or by a free incision in the long 
axis of the swelling, followed by curetting the abscess-cavity and by 
the usual antiseptic dressings. Constitutional treatment by iron, qui- 
nine, cod-liver oil, and the employment of a generous diet with milk, 
malt liquors, or wines are often required in broken-down and de- 
bilitated persons. 

Prognosis. — The prognosis, in uncomplicated cases, is generally 
favorable. The scar left by a suppurating gland in the groin is indel- 
ible, but it becomes less conspicuous with years. Sloughing and gan- 
grenous sores leave deforming cicatrices, especially when occurring at 
the apex of the glans, to which they usually give a peculiarly trun- 
cated shape. A just reserve should be made in all cases, compli- 
cated with syphilis or extensive fistulous sinuses, the latter, as men- 
tioned above, often persisting for years. 

MYCOSIS FUNGOIDES. 

(Gr., hvkt]q, a mushroom.) 

(Granuloma Fungoides, Granuloma Sarcomatodes, Inflamma- 
tory Fungoid Neoplasm, Ulcerative Scrofuloderm, Eczema 
Tuberculatum, Fibroma Fungoides, Lymphodermia Perni- 
ciosa, Sarcomatosis Generalis. Fr., Lymphadenie cutanee.) 

This disease was described first in 1814 by Alibert, as " Pian fon- 
goi'de." Its symptoms resemble those of that affection, though not 
in any way related to it. 

The disease is uncommon ; about three hundred cases have been 
recorded in literature r 1 but so many of these have been observed care- 
fully and fully reported that all the symptoms of the disorder are 
established. An attempt has been made to distinguish between two 
forms. There is, however, but one. 

Symptoms. — For convenience in description the symptoms may 
be grouped roughly in three stages, which, however, do not always 
occur in regular succession, and of which the first and second may 
never be manifested. 

" Premycosic Stage" (Erythematous Period [Bazin], Stadium 
Eczematosum [Kaposi], Erythrodermie Pityriasique en Plaques Dis- 
seminees). — This first stage is characterized by the occurrence of a 

1 For further discussion of the subject, see monograph by Wolters, Bibliotheca 
Medica, Abt. D. ii., H. 8, Stuttgart, 1899 (with sixteen illustrations and com- 
plete bibliography) ; Hyde and Montgomery, J. C. D., 1899, xvii., p. 253 (bibli- 
ography) ; Galloway and MacLeod, B. J. D., 1900, xii., pp. 153 and 187 (with full 
histological report on lesions of various types taken from three cases) ; Leredde, 
La Pratique Dermatologique, t. iii., p. 527 (bibliography) ; Breakey, J. C. D. r 
1902, xx., p. 316 (autopsy and histological report) ; and Stowers, B. J. D., 1903, 
xv., p. 47 (with recent bibliography). 



PLATE XL 




Prefungoid Stage of Mycosis Fungoides. 

(From a painting.) 



MYCOSIS FUNGOIDES. 719 

series of cutaneous phenomena of different types, which have been 
described as resembling, if not identical with, eczema, lichen, ery- 
thema, pityriasis rubra, psoriasis, urticaria, furunculosis, and other 
congestive and inflammatory cutaneous affections. In a contri- 
bution 1 based on a personal experience in thirteen cases and a 
review of the literature of forty-eight cases in which these early 
phenomena were described, we concluded, in common with a few 
other investigators, that these early dermatoses, though differing 
considerably in clinical type, have many characteristics in common 
and are the varied expressions of a definite morbid process. The 
term Pre fungoid, employed by Morrow, would designate better 
this stage than the generally accepted term premycosic. The mis- 
chief undoubtedly is declared with the earliest pruritic symptoms, 
and the skin-eruptions in the early periods of mycosis should be con- 
sidered as significant expressions of a general disease as the tumors 
themselves. 

The earliest phenomena vary greatly, and may imitate any of 
the above-named dermatoses. The most frequent lesions, however, 
are in the form of round or circinate, sharply defined, erythematous 
patches, psoriasiform plaques, or infiltrated discs, usually character- 
ized by scaling and by itching. These areas are commonly from 
one to six centimeters in dia-meter, but may be of any size, and in 
rare instances (as in one of our cases) the redness and scaling may 
be universal. Generalized vesiculation has also been noted. The 
lesions usually are dry; but at times may be moist, crusted, or even 
the seat of small papules and vesicles. The color varies through the 
different shades of red, orange-red, or scarlet, often combined with 
tints of brown or purple. As the lesions persist thickening and in- 
filtration of the skin are noted, and the patches become more sharply 
outlined, more distinctly circinate in contour, and, by extending 
peripherally while clearing in the centre, may either coalesce or begin 
to assume the gyrate and fantastic figures so characteristic of the 
disease. Itching is usually a pronounced feature, but may be absent. 
The course of the lesions is capricious, even more so than in eczema. 
One or all of the patches may disappear suddenly and spontaneously, 
only to return without apparent cause in old or new sites, and after 
intervals of days or months. Treatment, save by radiotherapy as 
noted below, either constitutional or local, seems to have almost no 
influence upon the course of the lesions. This stage, during which 
the patches come and go, may last a few months or several years 
(thirty, Dubreuilh) before the appearance of the more characteristic 
areas of infiltration. 

Period of Infiltration (Lichenoid Period \Bazin, Yiddl, Brocq, 
Fabre~] ) . — In what may be called conveniently the second stage, cir- 
cinate, sharply defined, elevated plaques and nodules appear, either 
in the site of previous lesions or independently of them or concur- 
rently with them. The nodules are pea-sized or larger ; the infiltrated 

1 J. C. D v 1899, xvii., p. 253. 



720 NEW-GROWTHS. 

plaques are button-sized to palm-sized, or larger, sometimes extending 
over the greater portion of the chest, back, or abdomen. The color 
varies from a bright pink through varying shades of red and occasion- 
ally of brown or violet. The surface may be smooth or verrucous, 
or fissured and excoriated as the result of scratching. The pruritus 
is usually severe, but may be absent. The shape and career of these 
plaques are almost, if not quite, diagnostic. They are circular or 
circulate, as a rule, and as a result of an extending periphery and 
clearing centre they are constantly changing in both site and con- 
tour, often moving over the surface in gyrate bands or lines, or assum- 
ing half-moon, crescent, horseshoe, kidney, or other, often fantastic 
and grotesque, shapes. Again, they disappear and reappear without 
apparent cause, as do the lesions of the first stage. While in many 
cases these variations in site and form require several months for 
completion, cases not infrequently occur in which the whole aspect 
of the disease changes in a few days. In one of our patients the 
lesions assumed the form of a curious network of connecting, broad, 
flat-topped ridges, between which were corresponding valleys of nor- 
mally colored and apparently normal integument. As a rule, the 
lesions on disappearing leave no trace of their previous existence, 
but they may be followed by areas of more or less permanent pig- 
mentation or of vitiligo. More rarely, circumscribed areas destitute 
of pigment and resembling leucodermatous patches, may occur in the 
skin where no preceding lesion has been observed. The symptoms of 
this period often occur with, or may be replaced by, those of the pre- 
ceding stage. The two periods together may last many years (four- 
teen in one case) before the appearance of tumors, though in excep- 
tional instances they may be preceded by tumor-formation. 

Fungoid Stage {Mycofungoid, Neoplastic Period). — In the so- 
called third stage, which in some instances is the first and only stage, 
the characteristic Tumors of the disease appear upon the face, scalp, 
chest, and other portions of the body. They are bean- to cocoanut- 
sized, or larger ; whitish, pinkish, pale, or dull reddish in hue, sessile 
or pedunculated, well rounded or lobulated, and distinctly circum- 
scribed. They are covered usually, before ulcerating, with a dry scal- 
ing or crusted epidermis. When developing from the plaques above 
described they may be quite flat. They may spring from any of the 
previously described lesions or from the sound skin. They occur 
upon all parts of the body, upon the palmar and plantar surfaces, 
the arms, the forearms, the thighs, the legs, the face, and the back. 
Often they are in various degrees pigmented, showing purplish, 
brownish, or even black colors. They are usually painful, and may 
or may not be tender. The pruritic sensations of the premycosic 
stage may now be absent. When the tumors have attained maturity, 
and before involution has begun, their appearance, especially upon the 
face, is characteristic. Here they are smooth, moderately firm, glob- 
ular, often lobulated, or sausage-shaped, of a peculiar reddish hue, 
and when numerous produce a lepra-like deformity, closing the eyes 



MYCOSIS FUNGOIDES. 



721 



in consequence of their size or weight, producing the leonine brow and 
the elephantiasic ear. 

Like the other lesions of this disorder, the tumors may disappear 
spontaneously, while others appear ; or they may all disappear to re- 
turn after uncertain intervals without known cause. As a rule, they 
leave no trace of their previous existence, though they may be fol- 
lowed by pigmentation or slight atrophy of the skin. Sooner or later 
some of the tumors degenerate, and lead to superficial ulceration, 

Fig. 129. 




Mycosis fnngoides. 



accompanied by adenopathy, usually followed by papillary excres- 
cences and mushroom-like growths of varying sizes from which the 
disease obtains its name. At the summit of these the hairs usually 
fall. At times they may be the seat of much more destructive ulcer- 
ation, though with but few exceptions this destruction is limited to 
the new-growth, and even large fungoid and apparently deeply ul- 
cerated tumors may disappear completely and leave no trace further 
than pigmentation and possibly a small atrophic scar. 

The general condition of the patient at first seems unaltered ; later 
when the tumors ulcerate, exhaustion occurs and the victim usually 
dies as a result of febrile processes, of intercurrent disorders, pneu- 

46 



7-22 



NEW-GROWTHS. 



nioiiia, tuberculosis, nephritis, leukemia, cachexia, or pysemia. 
When the tumors are many and ulceration extensive the appearance 
of the patient is repulsive in the extreme; the exhalations from the 
body are in the highest degree fetid, and the difficulty of procuring 
asepsis, hygienic care, and comfort for the wretched sufferer is well- 
nigh insurmountable. Extirpation of the tumors usually is followed 
by recurrence, frequently with added malignancy. 

The superficial and deep lymphatic glands may enlarge, and this 
-adenopathy, as in the case of the tumors, may subside to be replaced 

Fig. 130. 




Mycosis fungoides. 



later by similar involvement of the same or other glands. Other 
complications of the disease are : pleuropneumonia, pulmonary tuber- 
culosis, hemiplegia, and erysipelas. 



MYCOSIS FUNGOIDES. 723 

The duration of the tumor-stage is brief compared with the others, 
frequently death occurs within a few months, though it may be post- 
poned two or three years. 

Etiology. — The disease is more frequent in men than in women, 
often in those of unusual weight and size, and usually occurs between 
the thirtieth and fiftieth year of life, most often after the fortieth 
year, though in a few instances it began earlier, even in childhood. 
The disease bears no relation to tuberculosis, lepra, or syphilis. 
Though the cause of the disease is not definitely known, there can be 
little question as to its infectious character. It is produced probably 
by specific micro-organisms, but direct evidence of contagion and suc- 
cessful inoculation-experiments are wanting. 

Pathology. — The disease has been studied by many observers, in- 
cluding ourselves. While the reports of different investigators at 
first reading apparently vary widely, closer study of the recorded 
observations indicates that on the main point they agree. The early 
lesions show on histological examination oedema and dilatation of 
the vessels, especially the lymph-capillaries, with often some endothe- 
lial proliferation, and a more or less dense cell-infiltration that is 
limited usually to the upper part of the corium, except where it 
surrounds some of the deeper vessels in the forms of sheaths or 
" cuffs." Galloway and McLeod 1 described in the early stages a 
connective-tissue cell-infiltration not only about the vessels, but also 
about the hair-follicles, the sebaceous glands, the muscles of the hair- 
pouch, the ducts of the coil-glands, and occasionally along the lym- 
phatic spaces between the connective-tissue fibres. They conclude 
that the infiltration may originate in the cells of any of these struc- 
tures. The infiltration in some instances is diffuse, but sharply sep- 
arated from the deeper parts of the corium by a horizontal line, and 
from the rete above by a narrow layer of connective tissue. In other 
instances the infiltration occurs in round or irregular areas, separated 
by bundles of normal connective tissue. Where the cells are most 
compact they are supported by a very delicate fibrous structure made 
up in part of elastic fibres. Degeneration of collagenous and elastic 
fibres occurs in the late, but not in the early, stages of the disease. 
The cells forming the infiltration are in the main of the connective- 
tissue type, but in many cases they and their nuclei show the greatest 
diversity in size, shape, and staining qualities. Round, cuboidal, or 
irregularly shaped cells with little protoplasm and a deeply staining 
nucleus are numerous. Many of the irregular bodies are apparently 
fragments of cells. In many places the cells are packed so closely 
as to modify their shape and size. This multiformity of the cells 
is apparently characteristic of the disease, and Unna believes that it 
is due to the result of two antagonistic processes constantly going on, 
that is, cell-multiplication and cell-destruction, and that many of these 
odd forms are nothing more or less than cell-fragments. Mast-cells, 
multinuclear cells, and giant-cells are seen in some lesions, but are 
1 B. J. D., 1900, xii., pp. 153, 187. 



724 NEW-GROWTHS. 

absent in others. Mitotic figures are frequent. The papillae are 
enlarged, in places packed with cells, in others more or less cedema- 
tous, as also are portions of the subpapillary layer. The rete is every- 
where hypertrophied, the interpapillary processes being elongated, 
broadened, and frequently branched. In places the cells are swollen 
and oedematous, with spaces between them. Mitotic figures here also 
are numerous, especially in the basal layers. Wolters, in summing 
up the results of all investigations, justly states that no distinctly 
specific changes peculiar to the disease, have been recognized. 

As the lesions progress toward the tumor-stage the cells in the 
corium become more regular in form and size, and the rete becomes 
much thinner. In the fully developed tumors the rete usually is 
reduced to a few layers of cells (sometimes but one), but in some 
instances it dips down deeply into the growth in a way to suggest 
epithelioma were it not that these epithelial processes are very slender. 
Many of the tumors correspond closely in structure to sarcoma, others 
show the histological formation of granulomata. 

Numerous micro-organisms have been seen in the blood and tis- 
sues, and some have been cultivated, but none has been demonstrated 
to have any pathogenic relation to the disease. Among them may 
be named streptococci in the capillaries of granulation-nodules, and 
staphylococci in cultures from blood. Other examinations of blood, of 
infected tissue, and of tumors were wholly negative as to the discov- 
ery of cocci. Wolters agrees with other observers that the organisms 
recognized and cultivated are in general the results of secondary in- 
fection, and bear no etiological relation to the disease. 

It is alleged that mycosis fungoides is a form of sarcoma. The 
facts, however, that fully developed tumors disappear spontaneously, 
and that in but few instances has involvement of viscera been re- 
ported in mycosis fungoides argue against the claim. In the re- 
ported case of Brandweiner 1 in which metastases were found in the 
brain, the correctness of the diagnosis has been questioned. The 
autopsy in the severe case pictured in Fig. 130 showed no visceral 
involvement. Changes in the deeper organs have been found similar 
to those which occur in leukaemia and pseudoleukemia, but no defi- 
nite relations have been recognized between these conditions and the 
disease under consideration. The various conceptions of the disease 
held by diverse authorities is summarized by Jarish 2 in groups as fol- 
lows: (1) as a granuloma, by Kobner, Geber, Auspitz, Weisser, Dou- 
trelepont, Ledermann, Hochsinger-Schiff. (2) As an adenoid 
growth, the expression of a diathesis " lymphadenique," by Eanvier- 
Gillot, Demange, Fabre, Gaillard, Amicis. (3) As sarcoma or lym- 
phosarcoma, by Kaposi, Funk, Siredey. (4) As a disease sui generis, 
midway between adenomatosis and sarcomatosis, by Vidal, Brocq, 
Leredde, Paultauf. (5) As a disease sui generis, midway between 
granulomatosis and sarcomatosis, by Walther, Ullmann. There is 

1 Monatsk., 1905, Ixi., p. 417. 

2 Hautkrankheiten, Wien, 1908. 



fe 






■MM^^m^. 




MYCOSIS FVNGOIDES. 725 

a growing tendency among observers to class mycosis fungoides with 
the infections grannlomata or in the fifth group mentioned above. 

Diagnosis. — The age, weight, and often the protuberant abdomen 
of the patient are usually to be considered. In the early erythema- 
tous stages the disease is to be distinguished especially from eczema, 
psoriasis, urticaria, erythema multiforme, and dermatitis exfoliativa. 
While a positive diagnosis cannot always be made at this time, in 
the majority of cases a careful consideration of the typical features 
just described will leave little doubt as to the nature of the disease. 
The circinate contour of the lesions, their spontaneous disappearance 
and reappearance, and the rebelliousness to treatment of what appears 
to be a mild and superficial inflammatory process, are features not 
found to the same extent in any of the other dermatoses named above. 
Aside from the absence of these three marked characteristics in 
psoriasis there is much more thickening of the plaques and there 
are characteristic scales, while the situation, history, and other fea- 
tures of the lesions are usually sufficient for a diagnosis ; in moist 
forms of eczema the discharge and multiformity of lesions are both 
greater than in mycosis fungoides. 

When these early lesions of mycosis fungoides appear in irregu- 
lar patches the diagnosis from eczema can be made only after they 
have been under observation for weeks or months. In those excep- 
tional cases which begin as a generalized exfoliative dermatitis an 
early diagnosis is rarely possible. 

After the appearance of infiltrated plaques, or of well-developed 
tumors in case the other stages are absent, the diagnosis is usually 
clear. The infiltrated areas, nodules, and smaller tumors may at 
times closely simulate leprosy ; but the history, the absence of areas 
of anaesthesia and other characteristics of leprosy, and the histological 
examination should clear up the diagnosis without difficulty. The 
tumors are distinguished from those of sarcoma by their history and 
career, and by their final formation of characteristic fungoid, super- 
ficially ulcerating masses. 

Treatment. — We have employed radiotherapy for one year in an 
unquestioned case of prefungoid mycosis fungoides with excellent re- 
sults. The plaques have disappeared and the patient for months at a 
time has been wholly free from the symptoms of the disease. Each 
return of those symptoms has been combated successfully by the same 
measure. Jamieson, 1 Weidenfeld, Lustgarten, 2 and Elliot 3 have each 
had a similar experience. Observation, however, of these cases for 
nearly twenty years will be needed before one can predicate the pos- 
sibility of curing the disease by these measures. At present it can 
be said merely that the prospects of such a cure are brilliant and the 
immediate results highly satisfactory. The pruritus and complicat- 
ing dermatoses which may be present in the early stages may be 
treated locally with various soothing, protecting, and antipruritic ap- 

1 B. J. D., 1903, xv., p. 1. 
2 Archiv, 1903, Ixvii., p. 123. 
3 J. C. D., 1904, xxii., p. 185. 



72(5 NEW-GROWTHS. 

plications (see treatment of Eczema) according to the indications in 
each case presented. 

The comfort of the patient is to be secured by all measures, in- 
cluding anodynes in an advanced stage of the disease, and his strength 
should be supported by a generous diet and tonic regimen. Arsenic 
in full doses and by hypodermatic injection has been of apparent ser- 
vice ; Koebner reported one patient cured by this treatment. Locally 
ichthyol, bismuth oleate, and many other preparations have been of 
service in allaying the symptoms and retarding the progress of the 
disease. AVhen the affection is generalized, tepid baths are produc- 
tive of great comfort ; the use of boric acid, resorcin, aristol, carbolic 
acid, or some similar agent is indicated by the fetor arising from the 
person. The ulcerating masses may be protected by a wet antiseptic 
dressing, or after cleansing dusted with the zinc stearate compounds, 
iodoform, aristol, or other powder, and protected by a proper dressing. 
Extirpation of the tumors is proper when such a course will add to 
the comfort of the patient. 

Prognosis.- — The prognosis is unfavorable except as it shall be 
modified hereafter by radiotherapy. The patient may survive from 
a few months to a maximum of fifteen years, the average being from 
two to four years. After the development of tumors the patient may 
live but a few months or at most two or three years. Three cases of 
recovery are on record, one of the patients being relieved after an 
attack of erysipelas. 

LEUKEMIA CUTIS. 1 

Cutaneous and subcutaneous lesions of various kinds occur occa- 
sionally in association with the general disease termed leukemia. 
They are found both in acute and chronic types of the disorder as well 
as in the different varieties, lymphatic and myeloid. 

Symptoms. — In acute lymphatic leukemia hemorrhages both pe- 
techial and diffuse occurring in the skin and mucous membranes are 
frequently noted as are also ulcerations and necroses : the latter com- 
monly in the mucous membranes of the mouth and nose, less often 
in the skin. In chronic lymphatic leukemia lymphomatous nodules 
and tumors are found in the skin and subcutaneous tissues as well as 
in the mucous membranes. In myeloid leukemia these manifesta- 
tions may occur but less frequently than in the other variety. The 
skin in the latter variety is usually dry, lusterless, anaemic ; and may 
be the seat of a symptomatic erythema and urticaria with secondary 
complications, and occasionally true lymphomatous tumors. 

1 Literature : The following works, with articles referred to in their appended 
references, were consulted in the preparation of this article, in addition to special 
papers mentioned below: Nothnagel's Encyclopedia of Practical Medicine, Ameri- 
can Edition, 1905, volume devoted to diseases of the blood, pp. 539-637 (many- 
references) ; Unna, Histopathology, pp. 618-624, many references; Crocker, 3d ed., 
pp. 1036-1042; Nicolau, A Contribution to the Clinical and Histological Study of 
the Cutaneous Manifestations of Leukemia and Pseudo-Leukemia (Annales, 1904, 
p. 753), abstr. B. J. D., 1905, xvii., 234-235; Wende, Leukemic Lesions of the 
Skin, J. C. D., 1901, xix., p. 479; Shattuck, A Case of Lymphatic Leukemia with 
Purpura, J. C. D., 1904. xxii., p. 118. 



LEUKEMIA CUTIS. 727 

In general the cutaneous manifestations may appear to precede or 
follow the systemic disease, but at any time they are symptomatic of a 
grave disease of the blood. While the general symptom complex is 
often sufficient to correctly place the varieties of this disease from a 
clinical standpoint, the final diagnosis rests on the microscopic blood 
findings, the latter method being imperative in clinically mixed 
types. It is evident from a study of the literature that certain cases 
show characteristics that appear to be closely allied to mycosis fun- 
goides and sarcoma cutis; and opinions differ concerning their noso- 
logical position as to whether they represent a single one or a com- 
bination of two of the above disorders. 

There are two types of cutaneous lesions : a superficial and a deep 
variety. Both may occur in the same patient and division is made 
merely for purposes of description. In the first are hemorrhages, 
petechial and diffuse, papular, vesicular, urticarial and pigmented 
lesions, symptomatic erythema, diffuse scaling erythrodermia, and, in 
rare cases, a moist or scaling dermatitis accompanied by itching. 
Among the deeper lesions are ulcers and areas of necrosis, especially 
of the mucous membranes but also of the skin, induced by the break- 
ing-down of hemorrhagic or lymphomatous deposits. Nodules and tu- 
mors of various sizes, shapes, and colorations, also occur. All these 
lesions may develop on different parts of the body but show a predilec- 
tion for the extremities and face. 

The nodules vary in size up to that of a coffee bean and may be 
few or numerous, and occur especially on the extremities and face. 
They may be pale and waxy, reddish, brownish red, or yellowish red 
in color, firm or soft in consistency, movable with the skin, smooth 
or scale covered, oval, round, or flat, or even have depressed centres, 
and may be often accompanied by telangiectatic vessels. When abun- 
dant on the face, especially in association with larger growths, a 
leonine expression may be exhibited. 

The tumors vary in size up to that of a hen's egg or larger and 
like the nodules may be few or numerous. They grow slowly but 
continually as a rule, and only exceptionally break down. 

In a small proportion of cases of acute lymphatic leukemia green 
tumors (chloromata) occur. Children more frequently suffer and 
the tumors are usually seen on the face, temples, and cranium. The 
osseous system is especially affected, the bone marrow often being 
replaced by a peculiar greenish mass. The lymphogenous green tu- 
mors are deposited in the facial and cranial bones, in or under the 
periosteum or dura. In addition, practically every bone of the body 
has been described as the seat of these peculiar green tumors. 

Etiology and Pathology. — The cutaneous manifestations above 
described are a part of the general leukemic process which involves 
all portions of the human organism. The essential cause is unknown. 
The leukemic nodules and tumors are situated anatomically in the 
corium and upper part of the subcutaneous tissue and are made up 
of accumulations of lymphocytes. The infiltration of these cells is not 



728 NEW-GROWTHS. 

limited to the nodules and tumors but occurs throughout the skin 
even where no clinical evidence of its presence exists. The process be- 
gins as a perivascular lymphocytic infiltration especially about the 
coil-glands and gradually spreads upward toward the epidermis and 
downward into the subcutaneous tissue. The morbid growth usu- 
ally is separated from the epidermis by a thin layer of normal corium. 
While the infiltration may be dense, it spreads around normal struc- 
tures without destroying them. The lymph vessels in the region are 
full of lymphocytes which might mean that these cutaneous lympho- 
mata produce some of the specific cells found in the general circula- 
tion. In the cases resembling mycosis fungoides a multicellular in- 
filtration similar to that found in this disease is described. 

Treatment. — The treatment is that of the general affection under 
consideration. Radiotherapy is advised as a temporary alleviative 
measure. 

Lymphodermia Pemiciosa (Kaposi) (Fr., Erythrodermie Mycosique). 
— A group of cases is described in which the true leukemic process 
occurs later, the early manifestations being exhibited as a moist itch- 
ing dermatitis, with redness and swelling of the skin, and in which 
finally nodules and tumors form with a tendency to break down. 
These cases resemble in a high degree mycosis fungoides ; and Ka- 
posi's case is classed as such by Vidal, Hallopeau, Paltauf, Crocker, 
and others. 

PSEUDOLEUKEMIA CUTIS. 

The cutaneous manifestations occurring in this disorder corre- 
spond closely with those described in connection with lymphatic leu- 
kemia, though pruriginous papules and urticaria are more frequently 
found. The lymphatic cutaneous tumors are similar ; and a pseudo- 
leukemia may follow a general erythrodermia as occasionally happens 
in lymphatic leukemia. 

SARCOMA CUTIS. 

(Gr., cropf, flesh.) 

Sarcoma of the skin is a rare disorder characterized by the occur- 
rence, either as primary or as secondary developments, of a single or 
multiple, pea- to egg-sized and larger, pigmented and non-pigmented, 
cutaneous and subcutaneous, connective tissue neoplasms, having a 
marked inaptitude for ulceration, malignant in character, recur- 
ring after extirpation, and usually terminating fatally with involve- 
ment of the viscera. 

The term sarcoma, meaning a fleshy tumor, was employed origin- 
ally by Virchow to designate malignant connective tissue tumors: it 
included actinomycosis and other affections which are now known to 
belong to the granulomata. Dubreuilh has reported a case of infec- 
tive granuloma of sarcomatous aspect caused by multiple fragments of 
oyster shell imbedded in the skin. Carcinoma manifests its malig- 
nancy by ulceration and toxemia while sarcoma destroys life by the 



MELANOTIC SAECOMA. 729 

continuous development of new cutaneous and visceral metastatic tu- 
mors. At present there is no satisfactory classification of the sar- 
comata as anomalous and transitional cases are constantly observed. 
For convenience the group may be divided into: melanotic sar- 
coma, non-pigmented sarcoma, idiopathic multiple pigment-sarcoma- 
of Kaposi, and sarcoid growths. 1 

MELANOTIC SARCOMA. 

(Fevomelanoma, JSTevocarcinoma.) 

This is the most malignant and rapidly fatal of cutaneous neo- 
plasms. 

Symptoms. — The chief clinical characteristics of this affection 
are : its development in a mole, the production of pigment, the rapid 
involvement of the adjacent lymphatic glands, and metastasis. 

As the first evidence of the disorder a mammillated or pigmentary 
mole increases in size and assumes a darker color without or follow- 
ing irritation by caustics, electrolysis, friction, or traumatism ; or a 
wide area of black pigmentation may develop about a mole ; again as 
especially emphasized by Eve 2 there may be no appreciable change in 
the mole but the first evidence of malignancy may be the enlargement 
of the neighboring lymphatic glands ; it was the observation of cases 
of this category which once suggested that this form of sarcoma some- 
times originates in lymphatic glands. The disease may also begin by 
the sudden appearance of clusters of black macules and nodules pin- 
head- to small pea-sized, either independently or in close proximity 
to a mole. 

The pigment present varies greatly in amount in different cases 
and in different tumors of a given case ; hence there is a variation in 
their appearance as they present all shades of color: brown, light- 
brown, to jet black. In extreme cases the tumors become veritable 
pigment fabricators, so that a streak composed of tumor cells and 
black pigmentation may extend from the primary tumor to the nearest 
lymphatic glands ; or extensive areas of pigmentation may appear in 
the skin at some distant point ; pigment may also develop in affected 
lymphatic glands, and in metastatic tumors ; it may be sufficient in 
amount to cause melanemia and mel anuria but may be entirely absent. 

The lymphatic glands adjacent to the growth usually enlarge at an 
early date, and on microscopical examination pigment and tumor cells 
similar to those of the original tumor are found. Numerous metas- 
tatic lesions develop in the skin and in any of the visceral organs. 

1 For a full discussion of sarcoma and sarcoid, see Johnston, J. C. D., 1901, 
xix., p. 305 (a careful histological study with 7 excellent photomicrographs, 
a review of the subject, a proposed classification based on pathological findings, 
and bibliography), and ibid., 1903, xxi., p. 23 (a case of fibro-sarcoma) ; Pini, 
Bibliotheca Medica, Abt. D. ii., Heft 9, Stuttgart, 1901 (bibliography). De 
Amicis, Trans. Twelfth Internat. Cong. Med., Moscow, 1897 (abstr. in Brit. Jour. 
Derm., 1897, ix., p. 440); and Fordyce, Morrow's System, vol. iii., p. 670. See 
also special references under Sarcoid Growths. 

2 Practitioner, 1903, p. 165. 



730 NEW-GROWTHS. 

The disease may primarily appear in the eye, pharynx, or vulva, as 
well as in deeper structures. 

The lesions are bean- to egg-sized, usually single or multiple, very 
firm or doughy, sessile or pedunculated, spheroid or lobulated; and 
vary in color from grayish brown to inky blackness. The epider- 
mis may be discolored, thinned, and intact, or be ulcerated. The 
nodules are often surrounded by blackish puncta which eventually 
develop into tubercles. The lesion or lesions may for a long time 
remain stationary, or they may rapidly be followed by generalization 
as a result of local irritation, either by extension from a central point 
to adjacent tissue, or by transmission through the lymphatics to a dis- 
tance from the primary nodule. 

In a case lately observed by us the left lower extremity of a mid- 
dle-aged woman was studded with split-pea-sized to marble-sized, ink- 
black masses from the ankle to the middle of the thigh. The larger 
were always centres of groups of similar pinhead-sized black nodules. 
The skin of the region affected was swollen, inextensible, inelastic, 
and as firm as sole-leather. The disease had extended from the ankle 
upward in the course of a few months. 

Melanotic sarcoma is one of the most malignant and rapidly fatal 
of all neoplasms. Therapy is usually unavailing; and the prognosis 
is grave indeed, a fatal result usually occurring with rapidity after 
the occurrence of generalization, and commonly with visceral compli- 
cations by reason of secondary deposits. 

Unna, Gilchrist, 1 Schalek, 2 and others 3 believe that malignant 
growths arising from pigmented moles are usually (if not always) 
carcinomatous, hence the name nevocarcinoma, while Johnston and 
some others still contend that they are connective tissue growths, and 
should be retained in the sarcoma group. 

Melanotic Whitlow (Hutchinson) is described as a chronic ony- 
chia, displaying pigmented spots, suggesting silver-nitrate stains at 
the edge of the nail-fold, where eventually a fungus tumor forms with 
increase of pigment until the nail is exfoliated, and the process be- 
comes generalized. 

PRIMARY NON-PIGMENTED SARCOMA 

occurs mostly on the trunk ; the tumors may be few or number several 
hundred. When numerous they are usually bean-sized, but where 
there are few, they frequently attain the size of a hen's egg or are 
even larger, and are situated in the subcutaneous tissue. Scarcely two 
cases are alike. The lymphatic vessels and glands are not affected. 
The disorder may terminate in general debility and visceral metas- 
tases. 

1 J. C. D., 1899, xvii., p. 117 (investigation of two cases and of several pig- 
mented moles; bibliography). 

2 J. C. D., 1900, xviii., p. 145 (histological study of five cases, with review 
of literature). 

3 Cf. Whitehead, Johns Hopkins Hosp. Bull., 1900, xi., p. 221 (two cases, with 
review of literature) ; and Whitfield, B. J. D., 1900, xii., p. 267 (two cases, with 
references). 



IDIOPATHIC MULTIPLE PIGMENT-SARCOMA. 



731 



Eecurrent Fibroid of the Skin (Hutchinson), beginning usually in 
the lower extremities, and tending to slow extension, to rapid and 
persistent recurrence, and to ulceration and formation of fungous 
tumors, with ultimate marasmus, is set down by Crocker as a rare 
form of spindle-cell sarcoma. 

IDIOPATHIC MULTIPLE PIGMENT- SAR COM Ai (KAPOSI) 

owes its coloring to cutaneous hemorrhages and not to pigment-de- 
posit. The points which justify the classification of this as a form of 
sarcoma are: it is an affection of the extremities, developing sym- 
metrically in both hands or both feet; the tumors frequently disap- 
pear; and the lymphatic vessels of the infiltrations and tumors are 
affected. Pick has reported two cases in which the disease began as 
elephantiasis lymphangiectatica. It is the most common form of sar- 
coma of the skin. 

Symptoms. — The disease occurs chiefly in male subjects (from 
forty to sixty years of age) who have been laborers whose hands and 




Multiple hemorrhagic sarcoma. (Liebeethal.) 

feet become the seat of an oedema, accompanied by pruritus and other 
subjective sensations. Later, brownish, bluish-red, or dark-purplish 
spots appear, out of which develop pinhead- to pea-sized nodules, 

1 Eecent literature: Sellei, Monatshefte, 1900, xxxi., p. 413 (bibliography) 
and Archiv, 1903, lxvi., p. 41 (with plate and bibliography) ; Sequeira-Bulloeh, 
B. J. D., 1901, xiii., p. 201 (bibliography and colored plate) ; Bernhardt, Archiv, 
1902, Mi., p. 237 (bibliography), and ibid., lxiii., p. 239 (2 plates) ; Koehler and 
Johnston, J. C. D., 1902, xx., p. 5; Pick, Archiv, 1906, lxxxvii., p. 267. 



732 NEW-GROWTHS. 

gradually increasing in volume, discrete, tender, and often grouped. 
They may be the seat of lancinating and radiating pains. As they 
multiply a lardaceous infiltration progressively involves the depth of 
the integument, until an elephantiasic condition is produced, a hand, a 
foot, or an entire limb becoming of cartilaginous hardness, bluish in 
tint, and covered with a smooth, mammillated, squamous, or rugous 
envelope, which may be also the site of tumors of considerable size. 
These tumors are fewer in number and smaller in volume as they 
spread from the distal to the proximal parts of the limb. They may 
be sessile, pedunculated, and grouped, but they are always of a deep- 
bluish or violaceous tint. 

These growths may remain for a long time stationary; or they may 
be entirely resolved, the patient apparently securing complete recov- 
ery. Very rarely they ulcerate or exhibit slight erosions. At times 
they are covered with or surrounded by telangiectases, or by tissue ex- 
hibiting infiltration of blood. When the mucous membranes are in- 
volved, points, patches, disks, or infiltrations of a dusky-reddish or a 
bluish shade appear on the inner side of the gums, the lips, the tonsils, 
or over the palate ; and there is visceral involvement with lymphatic 
and vascular changes. The usual signs of physical exhaustion ensue, 
with fever, dysenteric symptoms, haemoptysis, and marasmus. The 
disease may last only from three to five years, but a duration of four- 
teen years has been recorded. Post mortem tumors have usually been 
recognized in the viscera. Only a few infantile cases have been 
recorded. 

Remarkable instances of complete recovery from this affection are 
multiplying. A patient with the hands completely relieved was 
shown at the International Dermatological Congress in London, in the 
year 1896, Kaposi having verified the diagnosis. A patient rapidly 
recovering from the same disorder is under our observation. It is 
doubtful if this condition be a true sarcoma — in the sense in which 
this term is generally accepted. 

Etiology.- — The etiology of the sarcoma group of disorders is un- 
known. According to Babes, sarcomata are frequently congenital, 
and are found not rarely in early youth upon the eyelids, the extremi- 
ties, and the genitalia. A belief in the parasitic origin of some, if 
not all, of the sarcoma group is entertained by some observers. 
Jurgens, 1 L. Loeb, 2 and others have grafted bito of sarcoma into the 
tissues of rabbits, rats, and mice, and produced tumors identical 
pathologically with sarcoma. Loeb transplanted sarcoma in this way 
through a number of generations. 

Pathology , — Sarcoma of the skin may be primary, but is probably 
more often secondary to the disease in deeper organs of the body. 
Histologically, it is a connective-tissue growth, made up largely of 
round- or spindle-cells, and corresponds closely to the structure of 

^entralbl. f. Cliirurgie, 1896. 

2 Jour. Med. Eesch., 1902, viii., p. 44. 



PLATE XLI1 




M 



ultiple Pigmented Idiopathic Sareomi 



SAECOMA CUTIS. 



733 



Fig. 132. 



sarcoma in other parts of the body, the spindle-cell being somewhat 
more frequent than the round-cell type. Other mixed types, as fibro- 
sarcoma, angio-sarcoma, or lympho-sarcoma, are seen occasionally. 
Kromayer 1 believes the epithelial cells undergo transformation into 
connective tissue, and Loeb 2 has shown that such a change may take 
place when epithelial cells are transplanted into connective tissue. 

In melanotic sarcoma, the pigment present is melanin ; it does not 
react to the ferro-cyanide test. The tumor is made up of small round 
epithelioid cells which stain poorly; some authors believe that they 
are of epithelial origin and others that they are connective-tissue or 
endothelial. They are clustered in alveolar connective-tissue. 

In the so-called " idiopathic multiple pigment-sarcoma " of Kaposi 
the pigmentation is due entirely to hemorrhage and the blood-slowing 
which follows. The growth is 
highly vascular, containing many 
newly formed vessels, the walls of 
which are very thin and often are 
made up of the cells of the tu- 
mor. The cells are spindle-shaped 
and the tumors are situated deeply 
in the cutis or in the subcutaneous 
tissue. In the older lesions there 
may be endothelial proliferation. 
The lymph spaces are dilated. In- 
volution occurs through destruction 
and resorption of the tumor cells 
and pigment, and the organization 
of fibrous tissue. Observers differ 
as to the propriety of classing the 
condition as a sarcoma or as a 
granuloma. 

Fordyce 3 describes several cases 
of localized angio-sarcoma of the skin in which the single tumor was 
identical histologically with the generalized sarcoma of Kaposi. 

In primary non-melanotic sarcoma the growth, according to Fendt, 
is composed of large round cells, which in some tumors are encap- 
sulated and in others diffused through the cutis. Where the infil- 
tration is diffuse the collagen disappears, though the elastic fibres are 
unmodified. At the centre of the nodules the cells undergo degener- 
ation and lose their staining power. Necrosis of the nodule may oc- 
cur, producing an abscess, which discharges through a small opening 
in the integument. 

Diagnosis. — The diagnosis rests upon the history, symptoms, and 
microscopical examination of the new-growth. Sarcoma should not 
be confounded with fibroma, epithelioma, gumma, or lupous nodules. 

1 Zeitschrift, 1896, iii., p. 263. 

2 An experimental study of the transformation of epithelium to connective 
tissue, W. W. Warren, 1899. 

3 Amer. Jour. Med. Sci., 1900, cxx., p. 159. 




Sarcoma : spindle-cells visible in sec- 
tions of cutaneous nodule removed from 
a sarcomatous patient. (About x300.) 



734 NEW-GEOTVTHS. 

Treatment of sarcoma is unsatisfactory. Surgical ablation of 
these tumors is apt to be followed by their speedy return. 

Koebner's injections of arsenic (usually Fowler's solution, 2 to 
4 drops in 1 to 2 parts of distilled water, repeated every second day 
for months, with gradual increase of the dose) seem to have proved 
successful in two cases. Wende reports a case improving under this 
treatment. Arsenic, potash, and ergot, internally; and salol, cam- 
phorated naphtol, aristol, and bismuth subnitrate, locally, have se- 
cured only transitory benefit. Successful results, but also several 
deaths, are reported from inoculation with cultures of Streptococcus of 
erysipelas. Favorable results have been reported in a few instances by 
Coley and others from injection of the combined toxines of this 
streptococcus and of Bacillus prodigiosus. In the majority of cases 
these measures are unsuccessful. Pusey, Coley, and others report 
favorable results with the .r-rays. With this agent they have succeeded 
in relieving pain, and in a few instances in causing a disappearance 
of the tumors. In a case of glioma in a child which had recurred 
twice after operation, we succeeded with the x-rays in preventing a 
recurrence of the growth after a third operation. 

Prognosis. — The prognosis in sarcoma is unfavorable, a fatal issue 
occurring in most cases. 

SARCOID GROWTHS. 

Sarcoid is a term used to designate cases in which there is a gen- 
eralized eruption of tumors of small size. They are seldom larger 
than a lima bean. For the present they may be classed conveniently 
with the Sarcomata. 

MULTIPLE BENIGN SARCOID (BOECK). 

It is now generally recognized that this affection is a granuloma 
in no way related to sarcoma. Some clinicians believe that it is an 
independent affection. Broeck has accepted the opinion of Darier 
that it is a tuberculide. The basis of this theory is the microscopical 
findings which are those of a tuberculide and the frequency with 
which patients suffering from the disease present distant foci of 
tuberculosis. 

Symptoms. — The following summary of Boeck's original article 
is an excellent description of the disorder. 

Clinically we find in a middle-aged, pale, thin man groups of 
lymph-nodes much swollen, and on examination a slight augmentation 
of the number of white corpuscles. At the same time there exists 
a wide-spread, somewhat symmetrical eruption, of firm nodules of 
varying size on the head and extensor surfaces of the trunk and ex- 
tremities. They range in size from a hemp-seed to a bean and the 
larger have irregular contours. They involve the whole skin and 
are movable with it. Only on the scalp is the infiltration not pal- 
pable. Here only yellowish outlines are seen. The color of the 
early nodules is bright-red, becoming darker, and finally yellowish or 



PLATE XLI1I 





■ 


IB 




: *^''l 






^j^JUF 


&~^ v ^H 




Clinical Varieties of Cutaneous Carcinoma. 



CARCINOMA OF TEE SKIN. 735 

brown. Slight scaling occurs on older lesions. They show a ten- 
dency to peripheral spreading and central depression. On the face 
they have a peculiar appearance, with blue centre and yellow border, 
a feature present in almost all cases. The nodules disappear 
finally, leaving as a rule a loss of substance in the skin, which may 
be white on the face, yellow on the back, and darker at the periph- 
ery on the legs. Exudation and ulceration never take place. A 
papular eruption grouped like lichen planus was seen on the inside of 
the thigh. A tendency to develop at the old injury should be re- 
membered. The symmetry is not such as is found in affections 
whose localization is evidently determined by central nerve influence. 
The disease seems to be benign and disappears under arsenic or 
spontaneously. 

Histology. — In benign sarcoma the following histological changes 
are described by Boeck. The areas of new-growth might be de- 
scribed as peri-vascular sarcomatoid tissue built up by excessively 
rapid proliferation of epithelioid connective-tissue cells in the peri- 
vascular lymph-spaces, with little addition of other varieties. The 
tumor soon begins to degenerate and the tissue is rarefied, showing 
a net-work of branched connective-tissue cells. It should be remem- 
bered that true giant-cells of sarcomatous type are found, though 
rarely. Compared with other new-growths of the skin this must be 
said histologically to possess affinity to sarcoma, and also to the 
very rare cases of so-called pseudoleukemia cutis described by Arning 
and Max Joseph. The new-growth here described, nevertheless, 
seems at present to be sui generis. It should be emphasized par- 
ticularly how different the histology of this process is from that of 
leuksemia cutis with its lymphoid tissue and small lymphoid cells. 

Treatment. — The disease may disappear spontaneously or under 
prolonged treatment with arsenic but in the majority of cases it 
progresses slowly through a number of years to a fatal termination. 

CARCINOMA OF THE SKIN. 

(Epithelial Cancer, Caecinoma Epitheliale, Eodent Ulcek. 
Ger., Epithelialkeebs ; Fr., Caistceoide. ) 

Great as has been the divergence of opinion respecting the nomen- 
clature, classification, and pathology of Cutaneous Carcinoma, there 
has been, none the less, a gratifying advance toward a unification of 
ideas on a pathological basis. 

As evidences of this advance may be cited the almost general adop- 
tion, as synonymous, of the terms Carcinoma and Epithelioma; the 
definite inclusion in the Cancer group of rodent ulcer and of Paget' s 
disease; and the recognition, simply as varieties, of tubercular, lenticu- 
lar, and melanotic carcinoma, as well as of numerous other forms 
which differ more in location and course than in any inherent pecu- 
liarity. 



736 



NEW-GROWTHS. 



Definition. — A carcinoma of the skin is a new growth, usually 
single, of greater or less malignancy, arising from the derma or its 
appendages, consisting of epithelial cells more or less atypical in 
structure and evolution, and extending into tissues where they do not 
normally occur, tending to give rise to metastasis, local or general, 
rarely spontaneously retrogressing but leading if not completely 
eradicated, to general cachexia and death. 

Classification. — Carcinomas of the skin may be classified: patho- 
logically, as squamous-celled, small- or cuboidal-celled, 1 and as cancer 
arising from the prickle-cells or from the basal-cells; 2 clinically, as 
superficial, deep, and papillary, and as benign and malignant ; an- 
atomically, according to their location, as on the lip, tongue, eyelid, 
etc. 

Symptomatology. — Superficial or discoid epithelioma usually is dis- 
played first upon the sound skin in the form of one or of several 





Fig. 133. 


■-..v^p* 










it* J • Ami 




?W tL& H 




mwKmr^ mm 'z^&j&i'- 9m 



Rodent ulcer. (Fordyce.) 



pinhead-sized papules, flat infiltration disks, or nodosities of a dull- 
yellowish, reddish, grayish, or dirty wax-like hue. The growth may 
also have its origin in previously existing skin-lesions which are 
both numerous and different from one another. Among the latter 

1 Fordyce, Jour, des malad. cutan. et syphil., 1901, s. vi., xiii.. p. 106 et seq. 

2 Krompeeher, quoted in Lexer-Bevan ' ' General Surgery, ' ' p. 939. 



CABCINOMA OF THE SKIN. 737 

may be named : fissures and excoriations (especially those long teased 
by caustic applications) ; warts, nawi, acneiform and molluscoid 
lesions ; and the dry or greasy epidermal scales often seen at the 
orifices of sebaceous glands in the faces of the aged. The outline 
of the newly developed growth as a consequence varies, being round- 
ish, linear, or irregular. As a result of accident or traumatism (es- 
pecially scratching and picking, which the history of a large propor- 
tion of all cases includes) there forms a superficial excoriation, which 
may be covered with a sero-sanguineous crust after the desiccation 
of its scanty and ichorous secretion. In the progress of its develop- 
ment it is often noticed that new foci of disease appear in the imme- 
diate vicinity of the first, represented by subepidermic indurated nod- 
ules, or superficial "pearls " resembling milia, whitish and lustrous, 
with marked tendency to vascularization, exfoliation, and superficial 
ulceration. 

Rodent Ulcer 1 {Jacob's Ulcer, Ulcus Exedens, Noli-Me-Tan- 
gere, Cancroid Ulcer) . — The characteristics of this form of superficial 
epithelioma are a roundish, fissured, or slightly angular contour, and 
a reddish or reddish-brown, irregular, granulating, and mamillated 
floor, covered with a thin translucent, viscid serum, which, in drying, 
suggests the effects of a varnish over the part. The edges of the ulcer 
are clean-cut, indurated, everted, usually well attached, and seen in 
horizontal profile, irregularly indented. The symptoms are slight 
at first ; the lymphatic ganglia and general health being unimpaired. 
Its site of election is the face, particularly the eyelids, nose, temples, 
and lips, though the genitalia, the hands, and the feet may be affected, 
Of two hundred and fifty cases collated by Heurtaux, in one hun- 
dred and ninety the face was attacked. 

Some English writers still describe the rodent ulcer as distinct 
from epithelioma, chiefly by reason of its individual peculiarities. 
Pathologically no distinction can be established between the two. 

The clinical features upon which this distinction is based are : the 
slow or intermittent development of rodent ulcer ; its tendency to de- 
stroy, as it extends, all the tissues within reach; its failure to impli- 
cate the system by secondary deposits or metastases ; its rounded and 
often widely everted edges, or better, lip, often distinctly vascularized ; 
its gouged floor exhibiting unequal levels ; its slight tendency to granu- 
lation ; its feeble or negative attempts at repair ; and, above all, its 
pearly gray, somewhat fluted border. The importance of the last 
mentioned finding cannot be over-estimated in the differentiation from 
lupus, syphilis, and other forms of skin cancer. Pathologically, this 
firm pearly border represents the strong connective tissue barrier upon 
the resistance of which depends the relatively mild course of rodent 
ulcer. All these symptoms are those of epithelioma, if one chooses to 
employ that term in its large and proper sense. The rounded or oval 
excavation, often exceedingly clean cut, at times with a corded and 

1 For full discussion of this type of epithelioma, see Dubreuilh et Anehe, An- 
nates, 1901, s. iv., ii., pp. 705-780 (seventeen figures; bibliography). 

47 



738 NEW-GEOWTHS. 

whitish rim, producing little if any pain, is characteristic of the 
rodent ulcer, yet in its extension it may exhibit all the symptoms of a 
deep epithelioma. 

" Crateriform Flcee." — Under this title Hutchinson des- 
cribes a form of epithelioma distinguished chiefly by rapidity of inva- 
sion. Its onset is by the formation of a roundish or conical mass 
which rapidly exhibits ulceration, a central crater forming with ex- 
ceedingly dense walls. 

The subsequent course of the lesion varies, its evolution being 
generally slow and accomplished in years. Sometimes having at- 
tained a maximum of size, the ulcer, if unmolested, long persists 
without appreciable change. In other cases the base cicatrizes and the 
epithelioma completely exfoliates, leaving an outlying linear ulcera- 
tion which may persist or spread. In yet other cases, after a persist- 
ence of from ten to twenty years, the ulcer may spontaneously close 
and the disease be at an end. Sometimes the ulceration is very super- 
ficial and slowly spreads in circles, segments of circles, or in irregular 
gyrate outlines, the older portions healing and cicatrizing while the 
border advances. Such lesions may cover considerable areas of the 
body and closely resemble the serpiginous lesions of syphilis and 
lupus. In many cases the papillomatous element is marked. To this 
form of superficial discoid epithelioma the name Paget's Disease is 
sometimes applied, as the process is practically the same as that which 
attacks the nipple and breast. Finally, any one of the destructive 
and malignant cancerous processes may be awakened, and the epithe- 
lioma be thus transformed from the type of the superficial to that of 
the deep variety of the disease. 

Paget's Disease 1 (Eczematous Epitheliomatosis of the nipple, 
Malignant Papillary Dermatitis, Cutaneous Psorospermosis) . — This 
disorder was first described in 1874 by Paget, 2 and has since attracted 
the special attention of a number of English, French, and American 
observers, including Thin, Duhring, Malassez, Darier, Wickham, and 
others. 

At the onset the condition suggests an eczematous involvement of 
the areola of the nipple, usually of one breast only, in women between 
forty and sixty years of age. According to Besnier and Doyon, the 
earliest change is without question a choking of the lacuna? of the 
nipple with corneous cells, and this either without the operation 
of any known cause or as a consequence of a localized eczema, a 
galactorrhoea, or other irritant. When early recognized the surface 
is intensely red and granulating, exuding copiously a clear viscid 
secretion, and producing subjective sensations of heat and burning, 
with intense or with moderate itching. The definition is distinct, 
the tissue is indurated, and the tenderness and pain are usually well 
marked and distressing. A conspicuous feature of the disease is the 
circumscribed infiltration of the skin and subcutaneous tissue, which 

'For bibliography, see Matzenauer, Monatshefte, 1902, xxxv., p. 205. 
2 St. Bartholomew's Hospital Eeports, 1874, p. 87. See also the paragraphs in 
this treatise devoted to this subject under the title of Eczema. 



CARCINOMA OF THE SKIN. 739 

on palpation suggests a large-sized coin or button let into the sub- 
stance of the areola and surrounding parts. 

When the disease has progressed to this point a cancerous infiltra- 
tion of the breast is usually recognized, at least after its removal, 
though even with great care it may not always be possible to dis- 

Fig. 134. 




Paget's disease of the breast. 

tinguish it before ablation of the gland. Crocker, however, holds to 
the belief that the disease of the nipple may endure for years without 
resulting retraction and development of scirrhus of the breast. The 
French recognize three stages: that in which the disease is limited, 
respectively, to the nipple, to the areola, and to the breast, the latter, 
of course, succeeding but not replacing the earlier. In all cases there 
is no attempt at repair ; and when abandoned to its course the ultimate 
result, after five to eight or more years, is a profound ulceration with 
destructive effects most noticeable in the region of primary invasion, 
the entire breast having become cancerous. Cases of Paget's disease 
affecting other parts of the body have been reported. In such in- 
stances, the process is identical with that of superficial discoid epithe- 
lioma described above. 

Deep, or Tubercular, Epithelioma. — This variety may originate in the 
manner already described, or may be from the first characterized by 
its specific features. It commonly begins by the formation of roundish, 
very firm, pea-sized nodosities, closely set in the skin and subcutaneous 
connective tissue, or be thus situated and well projected from the sur- 



740 NEW-GBOWTHS. 

face. In the course of months and years these nodules develop to 
form a nut- or even a small egg-sized tumor, roundish, dark reddish 
in color, and delicately vascular on its surface. This tumor may be a 
deep, flattish, or globoid development within the skin ; or be a well-de- 
fined nodule attached to it ; or (and this is a common form) be a dense 
thick, flattened plaque, a centimetre or more in diameter, its walls 



Fig. 135. 




jfiHrF. 1 *k 




^B"a j 




£r«. ( m 





Epithelioma of the forehead. (Douglas W. Montgomery.) 

steeply descending to the sound skin on either hand or moderately 
everted ; its center depressed by atrophic changes ; its surface shining, 
waxy, pinkish, or red, with ramifying capillaries. " Satellites" may 
form in its vicinity. 

Degeneration of these forms produces in the course of time an 
ulcer either like that described above, or one which deeply and de- 
structively encroaches upon the tissues beneath. In advanced cases 
the ulcer is irregular in contour, with a clean-cut, everted, in- 
durated lip ; eroded and " gouged," hemorrhagic and granulating- 
floor ; thin, viscid secretion which is foul and purulent at times when 
the resulting destruction is rapidly accomplished ; and a deeply at- 
tached base which may be perforated by a crateriform exulceration, 
extending down to or through muscles, fasciae, cartilage, and bone. 
The lymphatic ganglia become simultaneously involved, and a general 
cachectic condition is established. Death may ensue from marasmus, 
exhaustion, or hemorrhage in the course of several months or from one 
to three years. 

Papillary Epithelioma, — The cancer in this variety assumes the form 
of a malignant papilloma. In these cases a pedunculated or sessile, 
narrow or broad-based, smooth-capped or spongy and verrucous veg- 
etation is attached to the skin upon which it forms. It may origin- 
ally be as small as a pea, but usually it increases considerably in vol- 



PLATE XLIV 

FIG. 1 




Multiple Careinomata, with Diffuse Precancerous Hyperkeratosis. 

FIG. 2 




Section from a Small Tumor from the same patient. 



CARCINOMA OF THE SKIN. 



741 



ume, being not rarely pigeon's-egg- and turkey's-egg sized. The sur- 
face is either dry, reddish yellow, smooth, and lustrous ; exfoliating 
and secreting an offensively smelling sanguineous or translucent fluid ; 
or is moist, granulating, filamentous, and intermingled with hairs, as 
when it occurs upon the bearded cheek. Degeneration occurs later, 
fissures forming first; subsequently there appear superficial, .and fin- 
ally deep ulcers which ultimately assume all the features of the epi- 
thelioma described above. 

In some cases the epithelioma forms a soft, hemispherical, small 
nut- to egg-sized tumor, which upon pressure discharges numerous 
convoluted plugs, composed of epithelium, fatty masses, and a puru- 



Fig. 136. 








■E^-JK ^^^MfcEE^ 


' ■ SsHk' 


Eg -hEP^ 


V 1 


jm fcsT^&i 








^HaSs^fe^*- 


MB* i 


BHHI J^wHht 




,",-•' --''.^IgB^: 




1 '» : tI&v 





Carcinoma developing upon lupus vulgaris. 



lent secretion. The bases of these soft masses are remarkable for the 
ease with which they can be curetted and thus radically removed. 

A careful study of well-marked cases of papillary epithelioma in- 
dicates clearly that while ulceration often results, the center of the 
mass breaking down and furnishing a typical cancerous excavation, 
with hard and rounded or oval border, uneven base, irregular granu- 



'42 



NEW-GROWTHS. 



lating floor, and offensive discharge, the picture may be wholly dif- 
ferent. Occasionally the superficial process extends widely over the 
brows, cheeks, and chin, interspersed with raised cicatriform areas, 
suggesting that ineffectual attempts had been made to check the 
disease by surgical measures. These apparently atrophic disks, min- 
gled with vascular, florid, fungiform, pyriform, and oddly shaped 
outgrowths, are really cancerous infiltrations of the type of discoid 
epithelioma. They may be seen gluing the lobe of the ear to the 
cheek, or everting the lower lid, even when superficial papillary vege- 
tations are predominant features of the disease. 

The Rarer Clinical Types. — Cancer of the Connective Tissue. 
— This is rare as a primary cutaneous manifestation, but appears gen- 
erally secondary to a cancerous involvement of other organs, as of 



Fig. 137. 




Cancer en euirasse, chiefly involving the right side of the chest. 

the female breast. It is termed also Scirrhous, Hard, Fibrous, or 
Lenticular Cancer. It occurs either upon the skin covering a breast 
which has previously been transformed into a cancerous mass or as a 
cutaneous relapsing lesion after extirpation of the latter. Its symp- 
toms are pea- to bean-sized, densely firm, shining nodules, varying in 
color; or a more or less diffuse infiltration of the skin, of similar 
characteristic hardness, associated often with hyperemia of a purplish- 
red shade. 

When the cancerous infiltration is widely diffused and densely in- 
durated, involving a large portion of the integument of the thorax, 
the condition is termed by the French cancer en cuirasse (Fig. 148), 
a title first given by Velpeau. The malady is striking in its peculiar- 



CARCINOMA OF THE SKIN. 



743 



ities, and in the highest degree serious. The integument of a large 
portion of the chest, usually more in front, but also behind, and even 
a part of the anterior abdominal wall, is converted into a dense, 
leathery envelope, often so compressing the chest-wall as seriously to 
impede respiration. The edges of the infiltration are poorly defined 
save at the lines where tongue-like prolongations (languettes) of dull- 
reddish hue indicate the advance of the scirrhous process over the 
skin. The lymphatic circulation is obstructed, the glands enlarge, 
and, what is almost pathognomonic of the disorder, the upper ex- 
tremity, especially the forearm, usually of the side chiefly involved, 
becomes enormously swollen and cedematous. The nipple may or 
may not be retracted ; the breasts, one or both, are firmly bound down 

Fig. 138. 




Cancer en cuirasse. 



to the chest-wall by the cuirass of dense skin, hard, smooth or rough, 
shining, and either reddened in dull hues or of normal tint, here and 
there traversed by vessels, and breaking down into ulcerations, usu- 
ally first about 'he nipple, but also elsewhere. The process is one of 



744 NETV-GEOWTHS. 

the more rapid of the scirrhous metamorphoses of the body, as a fatal 
result is usually reached in a few months, though years have in some 
cases elapsed before death resulted. One of our patients, an unmar- 
ried woman with breasts in the virgin state, perished in the course of 
a few months, the cancer having originated in the skin. Milium-like 
masses, as large as grains of wheat, undergoing fatty degeneration in 
the centre and readily expressed like comedones, are occasionally 
present. 

We have had several cases of this disorder under observation, two 
being made the subject of a paper, 1 with illustrations of the clinical 
appearances, and morbid condition of the tissue. Two of the pa- 
tients were men. An instance of widely disseminated lenticular can- 
cer of the skin (illustrated by portrait), described by Morrow, 2 oc- 
curred in a healthy-looking woman as a secondary phenomenon after 
removal of primary cancer of the breast. Whether the nodules be, 
as to cutaneous manifestations, primary or secondary, the symptoms 
are generally the same. The lesions are closely set, shining, firm, 
reddish papules, infiltrations of a dull-reddish hue, miliary and pig- 
mented deposits, tubercles varying in size, subcutaneous nodules, and 
secondary results in the way of formidable ulcers, crusts, and fungous 
growths. 

Tuberose Carcinoma is a rare manifestation of the disease, oc- 
curring in the form of multiple, firm, peanut- or egg-sized, roundish 
nodules, which break down by ulcerative processes into deep losses of 
tissue. It is frequently accompanied or followed by cancerous in- 
volvement of other organs. It occurs chiefly upon the face, hands, 
arms, and chest, though also upon other portions of the skin of per- 
sons of advanced years, either as a primary or a secondary cancerous 
manifestation. Guinard 3 reports a cancer of this variety, remarkable 
for the smallness of the existing nodules, which varied in size from 
that of a hempseed to that of a pea. They covered the entire thorax, 
the back, and the right arm ; and had here and there broken down into 
ulcers. One of the latter was as large as the hand. 

Melanotic or Pigmented Carcinoma is that form in which both 
the epithelium and connective-tissue framework of the cancer are 
richly supplied with blood-vessels, and, probably, as a consequence of 
transudation from the latter, with an abundance of pigment-gran- 
ules in groups and clusters. These growths usually begin as hemp- 
seed- to pea-sized, single or numerous, soft or dense nodules, which 
may develop in time into tumors of considerable size, and which are 
stained in various shades from a grayish-brown or a slate color to a 
dead black, the pigment being occasionally displayed irregularly in 
streaks or bands over the surface of the growth. They occur over any 
portion of the surface, often upon the extremities and the genitals, 
starting frequently from benign pigmentary lesions, such as nsevi 

1 Amer. Jour. Med. Sci., 1892, ciii., p. 235. 

2 J. C. D., 1884, ii., p. 1. 

3 Union Med., 1881, xxxi., p. 205. 



CARCINOMA OF THE SKIN. 745 

and moles. Anatomically, the pigment is found to be deposited both 
between the cells and in the protoplasm of the cells themselves. 

In a few instances the disease is limited to single melanotic 
growths of this character. The cancer is apt to develop into the 
papillary form, furnishing thus fungoid vegetations which have a 
noteworthy tendency to degenerate into ulcers. Often such verrucous 
masses are seen surrounded by grayish or blackish papules, or by 
a diffuse cancerous infiltration of the integument; they also exhibit 
irregular pigmentation of the surface. The disease often appears 
in the viscera, in the form of disseminated cancerous nodules, each 
highly vascular, and exhibiting in varying quantity granules of pig- 
ment. The growth has usually a relatively rapid course and malig- 
nant career. Relapses are frequent, the amount of pigment usually 
increasing with each relapse. 

Eecent investigations (Cf. Melanotic Sarcoma) indicate that the 
majority if not all of the malignant pigmented growths which spring 
from moles and nsevi, and which in the past have been considered to 
be sarcomatous, are in fact instances of pigmented carcinoma. 

Endothelioma of the skin has been reported in a few instances 1 . 
In the three cases reported by Spiegler, 2 and in three others col- 
lected by him from literature, numerous tumors, varying in size from 
a pin to an orange, were located on the scalp. In some of the cases 
pea-sized tumors were seen also upon the face, neck, back, and chest. 
The course of the growths was comparatively benign. In Fordyce's 
case 3 a pea-sized tumor formed at the border of a lupous scar on the 
forearm. The histological structure of these growths is that of a 
small-cell epithelioma, except that the cells are grouped about dilated 
blood-spaces, and their origin from the endothelium of the blood-ves- 
sels can be demonstrated. 

Features of the Clinical Forms. — Epithelioma of the skin occurs 
also with multiform features, almost as numerous as the several dif- 
ferent lesions from which a cutaneous cancer may take its origin. 4 
Thus, a wart, a "button," a vegetation, a crack, an erosion may re- 
sult in a fissure that bleeds easily and refuses to heal. After months 
or years there forms an epithelioma, assignable to one of the clinical 
varieties described above. In other cases there may be a number of 
greasy scales upon the skin-surface resembling those seen in well- 
marked seborrhoea sicca ; and in one or two spots the removal of these 
scales offers to the eye a superficial erosion implicating the derma, 
bleeding freely, and, when undisturbed, crusting and slowly spreading 
under the crust rather than healing. In yet other cases a thin pellicle 
of apparently loosened epithelium, looking like a papery crust, is 
found, when removed, to cover three or more shallow ulcers, unex- 
pected and hidden from view by the tenacious pellicle which had 

1 For bibliography, see Waldheim, Arehiv, 1902, lx., p. 225. 
2 Arehiv, 1899, 1., p. 163. 

3 Amer. Jour. Med. Sci., 1900, cxx., p. 159. 

i Cf. Fordyce: " Clinical and Pathological Observations on some Eearly Forms 
of Epithelioma of the Skin," N. Y. Med. Jour., June 9 and 23, 1900. 



746 NEW-GROWTHS. 

protected them and beneath which they had indolently and painlessly 
developed. 

These varieties or types of epithelioma may coexist in different por- 
tions of the same integument, or the one may develop from the other, 
a malignant papillary growth springing from a superficial or a deep 
cancerous infiltration. Familiar examples of the disease are seen 
upon the eyelids and contiguous portions of the nose; the cheek and 
the lower eyelid, the latter being often drawn into ectropion by a cica- 
triform bridle or band; the nose or lip and adjacent mucous or osse- 
ous tissue ; and the glans and prepuce where the vegetating forms are 
of more frequent occurrence. The vast destruction wrought by the 
widest development and consequent degeneration of epithelioma is 
sufficiently recorded in the annals of both medicine and surgery. A 
woman sixty-four years of age was exhibited at the clinic, in the 
centre of whose face an ulcerating epithelioma had left a wide chasm, 
after destroying three-fourths of the nose and upper lip, and the hard 
palate with all the upper teeth and the antrum. The bones at the 
base of the skull were exposed. This case illustrated well the oc- 
casional remarkable tolerance by the system of the profoundest en- 
croachments of epithelioma. She was then digesting and assimilat- 
ing food with fair profit, and suffered chiefly from pain. She did not 
die until several months had elapsed, and then only as the result of 
hemorrhage from an ulcerative opening into one of the large arteries. 
Regional Epitheliomata. — Caxcee of the Head is recognized as 
constituting nearly three-fourths of all cancers of the skin. Upon the 
brow, the alas of the nose, the temples, cheeks, chin, scalp, or other 
part, the disease may begin either upon or beneath entirely normal 
skin, or in that which has pathologically been changed. The origin 
of the disease is usually ascribed to the picking, scratching, or shaving 
over a sebaceous wart in an old man ; or in similar traumatisms of ac- 
neiform, seborrhoic, or furuncular lesions in either sex. In other 
cases the dermatologist, consulted with reference to some other ailment 
of the skin, can recognize, in persons of the age most liable to such 
accidents, one or several pin-head-sized or larger milium-like nodules, 
clustered about the temples or the nose, that indicate the site of the 
awakened epitheliomatous change. The disease progresses slowly, 
spreading superficially along the alas of the nose in irregular lines, in 
more complete centrifugal outline over the temple and brow; almost 
symmetrically over the tip of the nose, and with odd indentations of 
contour in the dense integument immediately in front of the tragus 
of the ear. The vegetating forms are more common on the brow, 
scalp, and chin ; the " rodent-ulcer " type, over the temples and cheeks. 
The more superficial varieties in any part of the face may slowly be 
converted into the deeper. The flattened, egg-sized disks of infiltra- 
tion are more common on the cheeks and chin. 

The devastation produced by malignant cancer is nowhere more 
conspicuous than in the face. Cartilage, bone, muscle, and entire 
organs melt before its ravages with astounding readiness. Within 



CABCINOMA OF THE SKIN. 



747 



a period of two years a circumscribed flat epitheliomatous infiltration, 
limited for many months to one cheek, may spread to the point of de- 
stroying the ear, eye, and inferior maxilla of one side of the face, 
opening into the larynx and oesophagus, and not producing a fatal re- 
sult until the jugular vein of the same side is opened by ulceration. 

Cancer of the Lower Lip, far more common in men than in 
women on account of the tobacco-habits of the former, may arise 
either as a minute lobule or as a circumscribed thickening on or near 
the vermilion border, usually of one side, or as a linear, narrow, and 
shallow excoriation, often protected by a thin crust, extending well 
along the mucous edge of the lower lip that is in contact with the up- 
per when the two are lightly approximated. Later, the lip may be 
the seat of a defined tumor, small nut- to egg-sized, that may deeply 
involve the entire thickness of the lip, encroach upon the chin, loosen 
the teeth, destroy the gums, larynx, pharynx, tongue, and maxilla, 
and eventually produce one of the formidable and remediless chasms 
of the lower part of the face already described. 

Cancer of the Genital Organs is submitted to the surgeon 
more frequently than to the dermatologist. The glans penis, the 

Fig. 139. 




Carcinoma and pre-cancerous keratoses. 



clitoris, and the prepuce are occasionally the seat of a warty variety ; 
but the scrotum, labia, thighs, mons veneris, and abdominal walls, as 
well as the parts first named, may be involved in the superficial or the 



748 NEW-GBOWTHS. 

deep form of cancer. In persons of cleanly habits the superficial 
variety of epithelioma may persist in the genital region as indolent 
and innocuous as upon the face ; but where filth is permitted to ac- 
cumulate about the part (lochial, menstrual, catarrhal secretions ; pus, 
urine, feces, etc.) the spread may relatively be rapid. The ulcer is 
then deep, seated upon an indurated and very tender base, and has the 
steep, punched edge and hemorrhagic floor of the rodent ulcer. Ul- 
ceration may, later, open the rectum, vagina, corpora cavernosa, peri- 
neum, and deep perineal fascia, resulting in vast destruction that 
proves fatal by exhaustion of the forces of the patient. 

Cancer of the Extremities, particularly of the back of the 
hand, is at first usually papillomatous, or of the flat, superficial form. 
It may appear upon the left hand of right-handed patients. A form 
of peculiar interest to the dermatologist is that which is prone to de- 
velop upon the hand of the a>ray operator. A number of cases 
due to the persistent action of the Rontgen ray upon the unprotected 
hand have been reported in recent years. Its progress is indolent, and 
when properly treated is much less liable to grave ulceration than epi- 
theliomata in other situations. In special regions, especially on the 
lower extremity, where the force of gravity generally aggravates any 
ulcerative process, there may result caries, necrosis, fistules, loss of 
phalanges, etc. 

Cancer of the Mucous Surfaces may be primary or second- 
ary in origin. The mucous lining of the oral and nasal cavities, of 
the vagina, the rectum, and the balano-preputial sac may thus be in- 
volved, either by extension of the disease from the neighboring cu- 
taneous surface or by primary involvement of the mucous tissue. 
The most important, by reason of statistical frequency, is cancer of 
the tongue and buccal membrane, often having its origin in the leu- 
coplasic striations, plaques, or thickenings, known as " smokers' 
patches," ichthyosis linguse, psoriasis lingua?, etc., an etiological factor 
strongly emphasized by von Bergmann. A pinhead- to pea- or bean- 
sized superficial excoriation is usually the first lesion to which atten- 
tion is attracted, reddish in color, granulating, tender, and not often 
very painful ; or the beginning is a shallow fissure at the edge or on 
the tip of the tongue or on the mucous face of the lower lip, its long 
axis commonly at right angles to that of the organ upon which it forms. 
Beneath, with more or less rapidity (as a rule slowly) dense indura- 
tion occurs, lancinating pains dart from the affected region toward 
the ear or along the jaw, the submaxillary and other glands become tu- 
mid and tender, deglutition is painful, and in severe cases well-nigh 
impossible ; or from the nasal membrane the disease extends toward 
the palate, pharynx, or larynx, ulceration, when it occurs, opening 
up a vast chasm which represents all these cavities. In the vagina 
and the rectum a cancerous change may begin with merely a thicken- 
ing of the surface of the mucous membrane leading in the course of 
time to a superficial and later to a deep ulcerative process; or, as in 
cutaneous epithelioma, the papillary form may be represented in vege- 



CAECINOMA OF TEE SKIN. 



749 



tations, cauliflower-shaped, filiform, or simply warty and mammil- 
lated, that eventually degenerate and furnish the most formidable of 
destructive results. 

Etiology. — The exciting causes of carcinoma are unknown. The 
various theories relate to cell inclusion, parasitic disturbance of the 
proper relations of growth and functional activity, and congenital ten- 
dency of the cells. 1 The forms supposed to be etiologically related to 
Paget's disease, have been shown to be peculiarly metamorphosed 
epithelium. 

The predisposing factors in carcinoma include trauma, whether 
mechanical or chemical, as immediate excitants of the pathological 
process in the predisposed skin. In this way warts, nevi, the lesions 
of lupus and syphilis, though not in themselves cancerous, may 
when provoked inaugurate the disease. In this way, too, the irrita- 
tion produced upon the lips of the smoker by his pipe or tobacco ; 
the local disorder about the inner canthus of the eye resulting from 
occlusion of the lachrymal ducts ; the frequent teasing by caustic or 
other substances of the wart on an old man's hand ; and other agencies 

Fig. 140. 




A relapsing rodent ulcer in scar tissue back of the ear with lymph node meta- 
stasis over the mastoid process. Owing to the dense cicatricial tissue the growth 
appears as fine processes and strands made up of small compressed cells more sugges- 
tive of connective tissue than epithelial cells (Fordyce). 



disturbing the balance between waste and repair, aided at times by 
senile atrophic changes, may result in the development of an epithe- 
lioma. The danger of malignant changes in certain forms of kera- 



1 For a more complete discussion and bibliography see Macleod, 
of the Skin," 1903, pp. 120-122. 



Pathology 



750 NEW-GEOWTHS. 

tosis, 1 especially in later life, is recognized generally. The long-con- 
tinued use of arsenic may be followed by hyperkeratosis and epithe- 
lioma. 2 

The possibility of the transmission of cancer by heredity has 
almost ceased to obtain credence in the light of modern pathology, 
yet Broca reports sixteen deaths from cancer in one family, and 
Freiderich a congenital epithelioma in the child of a cancerous 
woman. 

The disease is eminently one of advanced life, being most fre- 
quent after the fortieth year, and a pathological curiosity in child- 

Fig. 141. 




Taget's disease of the buttock, showing the changes which take place in the epi- 
dermic cells. They are very much swollen from cedema, vacuolated, and have their 
nuclei pushed to one side. Many of them have lost their prickles. In the corium 
there is a dense infiltration of lymphocytes and plasma cells (Fordyce). 

hood. Kaposi reports one case at the tenth year. Only about 30 
per cent, of all cutaneous cases occur in women, a fact possibly ex- 
plained by the relative infrequency of the action of local irritants in 
those who are not subjected to the exposures incidental to the trades 
and laborious occupations of life. 

Pathology.- — The carcinomas which are secondary in the skin 
may be dismissed with a word ; their structure corresponds to that of 
the primary growth. 

Primary cancer of the skin occurs in the squamous and the cylin- 

1 Cf. Hartzell, J. C. D., 1903, xxii., p. 393 (discussion before American Derm. 
Assoc, with bibliography). 

2 Cf. Darier, Annales, 1902, s. iv., iii.. p. 1121 (references to literature). 



CARCINOMA OF THE SKIN. . 751 

drical-celled forms. 1 The squamous-celled type is at times described 
as originating from the r>rickle-cells which tend to become cornified 
and are of a less malignant nature; and the cylindrical-celled form 
as arising from the basal cells, not going on to cornification and being 

Fig. 142. 




A cancer of the leg, of the prickle or squamous cell type. Photograph shows cross 
sections of epithelial processes which have a concentric arrangement, their centers 
undergoing pearl-formation (Fordyce). 

of a more malignant type. Borrinan 2 speaks of the latter variety as 
carcinoma of the corium, for the lesions develop in the subdermal 
stratum. 

The squamous-celled form consists of solid cords of epithelium 
which, in the growth, invade the underlying tissue and in some cases, 
pile up above the skin level. The growth originates in the cells of 
the rete Malpighii. The layers of the epithelial rods, concentrically 
arranged, with the germinal cells at the base and the cornified cells 
at the center form, on section, the characteristic onion-like bodies 
known as epithelial pearls or nests. The parasites described as as- 
sociated with these tumors, are no more than cells which have under- 
gone hyalin and corneous changes. The so-called giant-cells are 
single multinucleated bodies or several cells fused into one. 

The cylindrical-celled variety arises from the cutaneous appen- 
dages, as a rule, probably from the sweat glands, and differs from the 
other type in its tendency to form gland-like structures. 

Though differing histologically, both forms are alike in that they 

1 Macleod, "Pathology of the Skin," p. 115 et seq. 

2 Ibid. 



752 XEJT-GEOWTHS. 

similarly invade the basement membrane and tissues where they do 
not normally exist. In their growth they excite, as a rule, an in- 
flammatory reaction in the form of a round-celled infiltration. Upon 
the amount and strength of the connective tissue arising from this in- 
flammatory reaction which is the safe-guarding barrier depends alto- 
gether the malignancy of the tumor. 

These carcinomas in their subsequent growth invade the contig- 
uous tissues, sparing none of the lymph channels, and finally, if death 

Fig. 143. 




Cylindroma. 

An epithelioma of the basal-cell type removed from the face. Hyaline degenera- 
tion of the interior of the tumor has resulted in the lace-like appearance. The tumor 
cells are small with chromatic nuclei and very little protoplasm. The connective 
tissue shows an inflammatory reaction (Fordyce). 

does not supervene from other causes, form general metastases, the 
structure of which corresponds to that of the primary growth. 

Diagnosis. — The diagnosis presents, as a rule, no difficulties. In 
those forms which are secondary the recognition of the primary tumor 
is conclusive. 

In the primary forms, the etiologic factors must constantly be 
borne in mind. The history of the case and the patient's age are 
primarily important. Thus, an eczematous condition of the nipple 
in a woman past 35, which shows no tendency to heal under the usual 
measures, ought, a priori, to be considered carcinoma until otherwise 
proven by the microscope. Or, in a middle-aged man accustomed to 
the use of the pipe, a refractory nicer on the lip must be looked upon 
as cancerous until the weight of evidence can be shown against this 



CARCINOMA OF THE SKIN. 



753 



diagnosis. Rodent nicer, in particular, in its manifold early varie- 
ties, is apt to remain long unrecognized as cancerous. 

Rodent ulcer has a benign course, is commonly found on the eye- 
lids, nose, temples, and lips, does not give rise to metastases (though 
Fordyce 1 mentions a case with regional involvement), and above all, 
has the unmistakable pearly border previously emphasized. Those 
conditions upon which rodent ulcer is prone to develop, or which 
resemble it from the outset can often be differentiated only by the 
history and course, and conclusively, by microscopic section. 

Lupus vulgaris is distinguished from rodent ulcer and other types 
of carcinoma of the face by its appearance, as a rule, in the young, 
by the " apple-jelly-like " border (seen with the diascope), and by the 

Fig. 144. 








Cylindroma of the scalp. 

The cells of this tumor are small and closely resemble those of the basal layer of 
the epidermis. Inside the cellular aggregations hyalin degeneration has taken place in 
the form of small cylindrical areas, from which the growth derives its name. Im- 
mediately surrounding the cell-masses the connective tissue has likewise undergone 
degeneration, appearing as a narrow homogeneous band of hyalin (Fordyce). 



other concomitant so-called " scrofulous " features — cervical ade- 
nopathy, adenoids and hypertrophied pharyngeal tonsils, dermatitis 
seborrhoica, otitis media, etc. 

The initial lesion of syphilis requires differentiation especially 
from rodent ulcer and carcinoma of the tongue and lip. The age of 
the patient (though advanced age by no means rules out chancre as 
hospital operative records not infrequently show), the history and 

1 Journal des Maladies Catanees et syphilitique, 1901, s. vi., xiii., p. 106. 
48 



754 



yKW-GEOWTHS. 



rapid appearance of the lesion, the recognition of spirochete pallida, 
and the subsequent appearance of the secondary manifestations of 
syphilis (the necessity for waiting for which in order to rule out 
cancer should not as a rule be the case) — all of these points determine 
the diagnosis. 

Secondary luetic manifestations can scarcely cause confusion. 

Tertiary lesions are recognized by the anamnesis, by their multi- 
ple character; the tubercular form by its serpiginous outline with 

Fig. 145. 




Carcinoma of the ear. 



tubercle-studded border, by the finding of characteristic scars, by the 
therapeutic test (which should be given a convincing but not dan- 
gerously long trial) and, if necessary, by the microscope. 

Syphilitic involvement of the penis, breast, and other parts are 
distinguished by the same criteria. 

The patch of blastomycosis does not present an indurated edge ; 
and forms fungous-like masses with miliary abscesses at the periphery 
which always show the specific organism. 

Paget's disease of the nipple is differentiated from eczem^ by the 
age of the patient, the progressive growth with no period of improve- 
ment, the sharply indurated limiting border, the lack of itching, and 
later by nipple retraction, rapid growth, and glandular involvement. 
The microscope may be necessary in doubtful cases. 



CARCINOMA OF THE SKIN. 



755 



Treatment. — Conspicuous in the recent contributions to the sub- 
ject of carcinoma of the skin stands the employment of :r-rays. It 
has been shown to be the therapeutic agent of choice in rodent ulcer, 
Paget's disease, and other superficial forms, when the condition is 
not hopeless. 

Since Stenbeck, in 1899, exhibited a patient from whom he had 
removed a rodent ulcer by the use of the ir-rays, 1 the value of the 
method in certain types of cutaneous carcinoma has been established 
by the reports of a large number of observers. 

The results obtained in our years of experience with :r-rays in 
the treatment of cutaneous carcinomata are extremely satisfactory. 
The exceptions are those cases in which regional metastasis has oc- 
curred and the cases where the growth involves the lower lip, and 
in some of those involving the tissues of the ear. When the carci- 

Fig. 146. 




Epithelioma. 



noma involves the lower lip excision should be advised except in the 
most superficial varieties ; where the growth involves the tissues deeply 
about the cartilages of the ear it is very resistant to x-rays and in 

1 Cf. Pusey, The Rontgen Eays in Therapeutics; Williams, The Rontgen Rays 
in Medicine and Surgery; Freund, Grundriss der Gesammten Radiotherapie, 
Vienna, 1903; Allen, J. C. D., 1903, xxi., p. 75; Sequeira, Brit. Med. Jour., June 
6, 1903; Hyde, Montgomery, and Ormsby, J. A. M. A., January 3, 1903. 



756 



NEW-GROWTHS. 



the majority of such cases excision followed by radiotherapy is prob- 
ably the best procedure. AVith these exceptions the method gives ex- 



Fig. 147. 




Carcinoma of lip. 

cellent results. (For description of apparatus consult the chapter 
on Radiotherapy. 

In a given case the treatment is given, as a rule, daily, or on alter- 

FiG. 148. 




Epithelioma of the ear. 



nate days. The average time consumed during treatment and recov- 
ery is two months. With the surrounding tissues properly protected 



CAECINOMA OF TEE SKIN. 



757 



with lead, exposures are made with a medium hard tube, its quality, 
however, varying with the depth of the growth. The distance of the 
target from the lesion varies from four to ten inches. The time occu- 
pied for each exposure is three to ten minutes. Treatment is sus- 
pended usually on the first appearance of reaction, and resumed, when 
necessary, after the latter has subsided. 

The chief advantages of radiotherapy lie in its painless application 
and excellent cosmetic results. It should be the method of choice in 
all superficial cases which, owing to location or to large areas involved 
can not be treated surgically without conspicuous disfigurement. 
The treatment is of special value in diffused hyperkeratoses and senile 
skins showing beginning malignant changes. For practically all sup- 
erficial lesions the method is satisfactory, but for circumscribed lesions 
more time is required than in simple excision. In deep-seated tu- 
mors, though radiotherapy is often successful if the growth be fully 

Fig. 149. 




Carcinoma of the lip. 



exposed to the surface, it is better to remove surgically as much of the 
tumor as possible and follow with the rr-rays. In deep-seated lesions 
beneath the unbroken integument, and especially those situated about 
the neck, we have had no success whatever further than relieving pain 
and temporarily retarding the growth. 

Destruction of smaller cancerous tumors of the skin may be per- 
formed with the aid of caustics, of which potassium hydroxide, in 
stick or in solution, is perhaps the most valuable, as its destructive 
action may be controlled by the topical employment of acids, and it is 



758 NEW-GBOWTHS. 

followed by less pain tban are some of the other chemical agents. 
Other caustic substances employed for a similar purpose are: zinc 
chloride, Vienna paste, silver nitrate, arsenical paste, resorcin, fuch- 
sin, and pyrogallol. The latter is highly recommended by Kaposi, 

Fig. 150. 




Epithelioma cf the cheek. 

not only because its application is unproductive of pain, but also be- 
cause it does not attack sound tissue. It is used in an ointment of 10 
per cent, strength. All such pastes and ointments should be spread 
upon cloths, and be applied for from three to six days. Opiates may 
be required, in the case of several of these agents, to relieve the con- 
sequent pain. 

Among the formulas used for caustic purposes are the following: 

]£ Creasoti, 3 SS ! 15 l 

Acid, arsenos., gr. iv; 1266 

Opii pulv., gr. ij; |133 M. 

Sig. For employment upon circumscribed surfaces. [Kaposi.] 

Marsden's paste, also employed as a caustic, is made by com- 
bining equal parts of gum arabic and arsenous acid with water suffi- 
cient to make a softish paste. By Robinson 1 it is preferred to others, 
and is applied on rubber plaster. 

Cosme's paste, as modified by Hebra, is prepared as follows : 

I£ Acid, arsenos., gr. vj ; 140 

Hydrarg. sulphuret. rub., 5ss; 21 

Unguent, aq. ros., 5ss; 15| M. 

Sig. Arsenical paste for external use, with caution. 

The method of its application is as follows : the paste is spread 

over a thin sheet of lint to the thickness of a knife-blade, and the lint 

is then cut to a shape and size corresponding with those of the tumor 

1 ' ' Treatment of Cutaneous Malignant Epitheliomata, ' ' Internat. Jour, of 
Surgery, 1892, p. 179. 



CABCINOHA OF THE SKIN. 759 

or ulcer to be destroyed. After its close apposition with the surface 
to be attacked the lint and paste should be covered with gutta-percha 
or other impermeable tissue, and a compress laid over the whole. In 
twenty-four hours the dressing is removed, the parts washed clean, 
and the same application renewed. By the third or the fourth day 
the destruction of the cancerous growth is usually complete, and the 
parts are ready for an emollient poultice, which should be applied for 
the three or four days during which separation of the slough occurs. 
The simple ulcer left is to be treated on general principles. The 
danger of arsenical poisoning is here reduced to a minimum ; the 
treatment is very effectual where patients consent to the delay as 
to time and to the severe pain which it occasions. 

The thermo- and galvano-cautery may also be often advantage- 
ously used for destruction of the growths. The advantages of the 
thermo-cautery are: the transitory character of the induced pain; 
the coal-like dressing left upon the attacked surface ; and the elegance 
of the resulting scar. Both measures find their highest value when 
employed after incision or erasion. 

Whatever method be employed, thoroughness is essential in attack- 
ing all portions of the new-growth; and it is well to encroach some- 
what upon the unaffected contiguous structure. The subsequent 
dressings should be made with simple or carbolated unguents, to 
which one of the salts of morphine may be added in case of continuous 
pain. The eschar usually separates in the course of a few days, 
leaving a simple granulating wound which may soundly cicatrize, 
and the epithelioma be thus radically relieved. In other cases the 
disease reappears in the ulcer or cicatrix, or, by recurrence of can- 
cerous nodules, in the previously sound integument. Even after 
these recurrences prompt destruction of the new-growth may finally 
be successful. 

But little confidence is placed upon any external treatment which 
does not effect complete destruction of the neoplasm. Yet there are 
those who highly esteem some of the procedures which are less radical 
in their aim, and which it is proper to mention here. 

Leveque, Vidal, Bergeron, Euthyboule, and others claim large 
success in the treatment of epithelioma by potassium chlorate. Lo- 
cally, the part is frequently touched with a saturated solution of the 
salt in glycerin and warm water, after which a simple ointment- 
dressing is applied. Vidal administers also the same drug internally 
in doses of 1| drachms (6.) in syrup and water before meals. It 
is possible that any remedial effect obtained from such measures 
should be attributed to the fomentations employed. Latterly, ben- 
zole and pyoktanin-blue have been reported as valuable topical appli- 
cations to small-sized epitheliomata. 

Injections of solutions containing cupric sulphate, iodine, alcohol, 
acetic acid, silver nitrate, sodium chloride, and hydrochloric acid 
have been practised, it is claimed, with some success; certainly at 
times with fatal results. This method is unquestionably inferior to 
others described above. 



760 NEW-GROWTHS. 

Prognosis. — In general, the prognosis of cutaneous cancer is 
grave. The relative degree of gravity largely will be proportioned 
to the variety, form, size, career, and complications of the growth in 
each case. The variety in which only " pearls " form in the skin is 
the most benign, as the lesions are usually isolated, and may, when 
unirritated, undergo spontaneous exfoliation. In other cases the dis- 
order for from fifteen to twenty years seems to make no progress of 
any sort. The malignity of a cancerous growth is usually propor- 
tioned to the quantity of epithelium as compared with the connective 
tissue present; the more abundant the latter, the more favorable the 
prognosis. Naturally, also, the deeper and the more destructive the 
growth, the fewer are the chances of ultimate recovery. Excessive 
pain and adenopathy are unfavorable symptoms in any case. Koch 
gives statistics of the results of operations, at the Erlangen Clinic, 
for the removal of epitheliomata of the lower lip, in one hundred and 
thirty-one patients exhibiting primary lesions. One hundred and 
fifteen of these were for the time " cured " ; four had speedy relapse ; 
and three were, at the date of writing, suffering from recurrence of 
the disease. 

The superficial types — especially rodent ulcer and Paget's dis- 
ease — Avhen recognized early and appropriately treated offer by far 
the best prognosis. 



CLASS VII. 
SENSORY DERMATO-NEUROSES. 



A number of skin-diseases are more or less dependent on neuro- 
pathic conditions, and could probably be classed as sensory., motor, 
vasomotor, or trophic dermato-neuroses. Morris 1 and Leloir, 2 and a 
few others attempt such a classification; but in the large majority of 
these dermatoses the neuropathic element is not so well understood as 
are some other features. In this chapter are considered only the sen- 
sory dermato-neuroses, that is, those disorders in which there is dis- 
turbance of sensation without other recognized changes in the skin. 

These purely sensory dermato-neuroses are commonly described 
under four headings: hyperesthesia, anaesthesia, dermatalgia, and 
paresthesia (including pruritus). 

Bronson 3 calls attention to the fact that cutaneous sensation is 
complex and made up of a number of elements which he describes as 
common sensation (or mere subjective feeling), including the sense of 
pain ; the sense of temperature ; the sense of touch, including the pres- 
sure-sense and the sense of contact; and a special sense of a higher 
order, which is exercised in feeling for or of a definite object, and 
which he terms the sense of Pselaphegia. This sense includes and 
is dependent upon the preceding elements, and is ranked with the 
special senses of seeing, hearing, and smelling. Any one of the above 
named senses may be exaggerated, defective, or perverted, while the 
others remain normal, or all may be involved simultaneously. 

HYPERESTHESIA. 

(Gr., lirip, above; alo-d-Tjcie, sensibility.) 

Hypersesthesia is an exaggerated sensitiveness to external impres- 
sions. In this condition the abnormal sensations are aroused by 
contact with an external body, and do not arise spontaneously, as in 
dermatalgia and in paresthesia. The distinction between these con- 
ditions may often be difficult to recognize, since two or more of them 
may. coexist ; or the hyperesthesia may be so excessive that the slight- 
est unrecognized current of air is sufficient, to produce a marked 
sensation. Finally, in some forms of hyperesthesia abnormal sen- 
sations may result from irritation due to mental or emotional causes. 

1 Diseases of the Skin, London, 1898. 

2 Twentieth Century Practice, vol. v., p. 749. 

3 Morrow's System, vol. iii., p. 725; and N. Y. Med. Eecord, Oct. 18, 1890. 

761 



762 SENSORY DEBMATO-NEUEOSES. 

It is evident that this last- type of hyperesthesia can be differentiated 
with difficulty, if at all, from paresthesia. 

Cutaneous sensation may be exaggerated as a whole, but the senses 
most commonly involved are those cognizant of contact and common 
sensation, including the sense of pain. In mild cases there is merely 
an unusual sensitiveness to contact with foreign bodies, such as the 
clothing, but in severer forms the light touch of a feather or slight 
currents of air over the skin may be almost intolerable. In the con- 
dition known as Hyperalgesia the sense of pain is greatly exaggerated, 
while the sense of touch is diminished. As a result, the slightest 
contact with an object causes great pain, but the nature of the object 
causing the pain is not recognized so distinctly as in health. In 
some instances it is the temperature-sense alone that is involved, as 
a result of which the surface is exceedingly sensitive to cold, or, more 
rarely, to heat. 

Hyperesthesia, involving one or all of the senses mentioned above, 
may be mild or severe, and may be limited to restricted areas, as in 
tabes or leprosy ; to certain regions or to one side of the body, as in 
hysteria; or it may affect the entire surface, as in disease of the cord, 
in neurasthenia, and in other disorders of the nervous system. 

The causes of hyperesthesia are found in various functional and 
organic disorders, central or peripheral, of the nervous system. 

In connection with the hyperesthesie may be mentioned a condi- 
tion which cannot be considered pathological in itself, though it is 
often dependent upon pathological states. Reference is made to the 
unusual development and acuity of the touch-perception, or sense of 
pselaphegia, as a result of which contact with a foreign body gives 
the perceptive centres a more delicate and complete impression of that 
body than would normally be obtained. This unusual sensitiveness 
of the touch-perception is seen frequently in the blind, and may even 
be cultivated. It occurs also in the hypnotic state; in intoxication 
from alcohol, or from cannabis indica; in hysteria and some other 
mental and nervous disorders ; and in conjunction with the other 
forms of hyperesthesia. 

Treatment is that of the nervous disorder upon which the hyper- 
esthesia depends. 

DERMATALGIA. 

(Gr., depfia, skin, and a'/.ynq, pain.) 

( TsTeue algia Cutis. ) 

In this morbid state the integument becomes the seat of painful 
sensations, which may or may not be associated with a hyperesthetic 
condition. This disorder is much more frequently partial than gen- 
eral, being in the larger number of cases a local expression of some 
disease of the nervous centres or tracts. It is observed usually in 
middle life, and in women more than in men. Its symptoms vary 
in severity from a slight burning to a state of torture that defies de- 



DEBMATALGIA. 763 

scription. In character the pain is differently described as compar- 
able to that produced by friction, incision, penetration, contusion, or 
burning of the integument, as also to the passage over the part, of 
streams of very hot or of cold water, or the electric current. With 
this there is commonly associated an undue sensitiveness to contact 
with foreign bodies. The skin presents no objective signs of disease. 
The disordered sensations may be limited to the scalp, the region 
of the spine, or the palmar and plantar surfaces. In the latter situ- 
ation it is often significant of some obscurely developed systemic dis- 
ease, such as syphilis, rheumatism, or locomotor ataxia. In a mid- 
dle-aged woman a persistent dermatalgia of the interscapular region 
was associated with confirmed gastric dyspepsia. In other cases 
the disorder is dependent upon disturbance of the uterine function. 
It is occasionally observed as one of the rare signals of the occur- 
rence of the menopause. 

It is to be noted that the severe dermatalgia associated with dis- 
orders of the uterus in women is occasionally succeeded by a cutaneous 
lesion. In a middle-aged clysmenorrhceic patient under observation 
a pea-sized hemorrhagic bulla appeared over the forehead after sev- 
eral weeks of frontal suffering. Buck 1 also reports dermatalgia of 
the brows and wrists in a young woman who had frequently miscar- 
ried followed by recurrent formation of a vesicle which accomplished 
its career of rupture, crusting, and erosion in a stadium of from five 
to seven days. 

Diagnosis. — The disease is to be differentiated from hypersesthesia 
of the skin, with which it frequently is associated and from which it 
often cannot be distinguished with certainty, as it is not possible al- 
ways to exclude slight sources of external irritation ; and further the 
diagnosis must be based largely upon the observations and statements 
of the patient. Painful affections of deeper parts, muscular, ner- 
vous, aponeurotic, and visceral, must also be excluded. Severe pain 
limited strictly to the skin of the lumbar region, with hyperesthesia, 
may precede the occurrence of perinephritic abscess. 

Treatment. — The treatment is to be directed to the disorder of 
which, in the great majority of cases, the dermatalgia is merely a 
local symptom. Quinine, the salicylates, iron, arsenic, and zinc phos- 
phide are often indicated. Temporary relief, however, may be af- 
forded by the local application of a rubber bag filled with very hot or 
very cold water ; sometimes by an alternation of the two, each for a few 
moments at a time. Sponging the part with very hot water is also 
useful, continued for longer periods, and followed by swathing in 
cotton-wool covered with Lister protective. High frequency cur- 
rents over the cord are often of special value. In some cases anodynes 
may be used topically with advantage; especially cocaine, opium, 
aconite, belladonna, or stramonium in oily combinations. In other 
cases relief is had by painting the parts with Squibb's mercuric oleate 
and morphine. The skin should generally, in the interval of applica- 
1 PMla. Med. and Surg. Reporter, 1881, p. 677. 



764 SEXSOEY DEEMATO-XErEOSES. 

tion, be protected by a dusting-powder; and the clothing worn next 
the skin should be of an unirritating character. 

Causalgia is a term chiefly employed by Weir Mitchell, to desig- 
nate a sensation of burning and pain, with tenderness, occurring in 
different regions of the integument affected with " glossy skin." The 
sensitive area in these cases, is supplied by the filaments of a single 
nerve. 

Causalgia is distinguished from the pain of neuralgia, sciatica, 
etc., by the localized affection of the skin which is the seat of the 
abnormal sensation ; and from the pains of rheumatism by the absence 
of the muscular soreness accompanying this last. In the gouty state 
with erythematous areas, often shining, over the painful joints, the 
recognition of any distinction might be attended with difficulty. In 
pruritus, the itching sensation is invariably the predominant symptom. 

MERALGIA PARESTHETICA.* 

(Gr., fiepoc, a part.) 

Under this title Dr. James C. White 2 describes one of the con- 
ditions due to derangement of sensibility in the skin where the region 
of the disordered sensation was strictly limited to a portion of the 
surface of the left thigh. The patient was fifty-five years of age 
and had suffered for six months from abnormal sensations in the 
skin of the region invaded, first appreciated after active exercise in 
walking. 

The perverted sensations were described as " tingling like that 
produced by striking the ' crazy-bone,' tensity as in tearing, formica- 
tion, the sensation of the bursting of a bubble, dull deep aching pain 
of fatigue." The sensations were increased in the recumbent posi- 
tion, when the limb was over-stretched or strained, and when it was 
deeply impressed with the hand. On the production of artificial hy- 
peremia, the part became congested in a purplish hue, receding more 
slowly than on the opposite side. The entire area was found, on test- 
ing with the point of a needle, less responsive than the corresponding 
part of the other limb ; and there was complete anaesthesia above the 
patella. The author did not suggest any remedies for the control of 
the disease. 

ERYTHROMELALGIA.s 

(Gr., kpvdpdg-, red, and a/joq. pain.) 

(The Red Neuralgia.) 

Under this title Weir Mitchell in 1872, and later in 1878 and 
1897, described a chronic disorder in which one or more portions of 

1 Bernhardt, Erkrankungen des peripherischen Nerven, 1895; Oppenheim, 
Nervenkrankheiten, 1905. 

2 J. C. D., 1906, xriv., p. 160. 

:i Bibliography : Arcangeli, Monatshft., 1905, sli., p. 646. Auche and Lespin- 
asse, Eev. de med., Paris, 1889, p. 1049. Baginsky, Verhandl. der Berl. med 



EB¥T HBO MELALGIA. 765 

the surface of the body, particularly over the extremities became the 
seat of pain, redness, and local elevation of temperature. Since then 
Graves, Eaynaud, Paget, Vulpian, Eulenberg, Dreschfeld, Mackenzie, 
and others have described cases more or less allied to the type origi- 
nally depicted. 

Symptoms. — The symptoms are developed usually in persons of 
early middle age, in men more often than in women, particularly in 
those who are engaged in physical labor requiring an erect posture. 
After a variable period of malaise or suggestions of ill-health, a burn- 
ing pain occurs in one or more parts of the local extremities, made 
worse by posture and movement but commonly relieved in the re- 
cumbent position. The sensations are those of burning and pain 
which recur with exaggeration after prolonged exertion in the erect 
posture and are soon followed by redness over the fingers, the toes, the 
heel, and external or inner face of the foot. One or all digits and one 
or all members may be involved. The arterial pulsation becomes ex- 
cessive and the veins distended, with throbbing of the part. The 
hyperesthesia may be excessive to both heat, cold, and pressure; the 
reflexes are normal or exaggerated; the surface-temperature of the 
parts affected rises two or three degrees above the normal ; the swelling 
is slight ; sometimes there is pitting on pressure. All symptoms are 
relieved by rest and cool applications. 

In some cases the hands as well as the feet are involved and pains 
occur in the head, neck, shoulders, elbows, and other parts. In other 
cases instead of redness, the parts exhibit a special pallor. Mitchell 
lays great stress in diagnosis on the color of erythromelalgia, rosy red, 
later purplish red, as distinguished from the livid red in Raynaud's 
disease. In some cases vesicles form ; in others pinhead-sized no- 
dules ; in yet others the subcutaneous tissue is indurated ; the finger- 

Gesselschaft., 1892, p. 241. Bury, Judson, Treatise on Peripheral Neuritis, 1893, 
p. 386. Collier, James, Lancet, Aug. 13, 1898. Dehie, Berl. klin. Wochenschr., 

1896, p. 817. Edinger, Neurolog. Centralb., 1893, p. 657. Engelen, Abstr. in 
Monatshft., 1908, xlvi., p. 555. Eulenburg, Verhandl. der Berl. med. Gesell- 
schaft, Erster Theil, 1892, p. 239; Neurolog. Centralb., 1893, p. 657. Prankel, 
Wiener klin. Wochenschr., 1896, pp. 147, 170. Gerhardt, Berl. klin. Wochen- 
schr., 1892, p. 1127. Graves, Clin. Lect., vol. ii., p. 586. Hann, Abstr. in 
Monatshft., 1908, xlvi., p. 555. Henoch, Berl. klin. Wochenschr., 1892, p. 1146. 
Henry, F. P., Journ. of Nerv. and Mental Dis., 1890. Koch, Berl. klin. Wochen- 
schr., 1892, p. 1146. Landgrat, Berl. klin. Wochenschr., 1892, p. 1146. Lewin 
and Benda, Berl. klin. Wochenschr., 1894, p. 53. Machol, Berl. klin. Wochenschr., 
1892, p. 1319. Mackenzie, Stephen, Brit. Med. Journ., 1879, ii., p. 704. Mitchell, 
Weir, Phila. Mecl. Times, 1872, pp. 81, 113; Amer. Journ. of Med. Sciences, 
July, 1878, p. 17; Clinical Lessons on Nervous Diseases, 1897, p. 177. Morel- 
Lavallee, Bull. Soc. Franc, de Dermat. et Syph., Paris, 1891, ii., p. 354. Morgan, 
Lancet, Jan. 5, 1889. Paget, St. Barth. Hosp. Eep., 1871. Pezzoli, Wiener klin. 
Wochenschr., 1896, p. 1263. Prentiss, Trans. Assoc. American Physicians, Phila., 

1897, p. 303. Eolleston, Lancet, 1898, p. 783. Boss, Diseases of the Nervous 
System, 1883, vol. i., p. 662, Seeligmuller, Lehrbuch der peripheren Nerven und 
des Sympathicus, Bd. v., p. 37. Senator, Berl. klin. Wochenschr., 1892, p. 1127. 
Sigerson, Progres Medical, 1874, pp. 229, 246. Strauss, Soc. med. des hopitaux, 
March, 1880. Sturge, Allen, Trans. Clin. Soc, 1879, xii., p. 156. Thoma, Archiv 
fiir patholog. Anat., 1883, xciii., p. 496. Idem, Deutsches Archiv fur klin. 
Medicin, 1888, p. 409. Vulpian, L'appareil vasomoteur, vol. ii., p. 623. Wood- 
nut, Journ. of Nervous and Mental Diseases, Oct., 1884, p. 627. 



766 SENSORY DERMATO-NEV ROSES. 

ends become tense and shining; or there is clubbing and thickening 
of the nails. In extreme cases the muscles of the limbs have become 
somewhat wasted, probably from disuse of the limb. 

Etiology. — Some patients are unquestionably hysterical ; in others 
there are definite indications of paralysis ; in yet other cases, there are 
signs of cerebral weakness (immobile pupils, exaggerated reflexes, 
and mental hebetude). Few cases occur in early life, although pa- 
tients aged sixteen to twenty have been recorded ; the most are males 
in middle life who have been engaged in heavy labor in varying tem- 
peratures. Traumatism seems to have been effective in a few cases. 

Pathology. — It is now generally believed that the disease is pro- 
duced by a peripheral neuritis, although in two cases recorded careful 
examination of resected nerves resulted in the discovery of nothing 
abnormal. Arteriosclerosis, even of the smallest arteries, is responsi- 
ble for some of the conditions named above. 

The disease has been found to result from trauma (in one instance 
after a railway accident) ; and to concur with paralysis, Graves' dis- 
ease, tabes, multiple sclerosis of the cord, alcoholism, osteomalacia, 
and myelitis. The morbid condition is rather a symptom-complex 
than a malady sui generis, the external phenomena being due either 
to central or peripheral irritation, inducing either functional or or- 
ganic change. 

Intermediate cases between erythromelalgia and Raynaud's dis- 
ease have been recorded by a number of observers (Morrell-Lavallee, 
and others). 

Treatments — The best results are secured by long rest in the 
recumbent position ; faradization of the nerve centers ; high frequency 
currents ; cold applications during paroxysms, when required ; and a 
nutritious dietary. Nerve stretching and nerve excision have been 
followed by questionable results. 

Prognosis. — The patient exhibiting these symptoms are rarely 
improved by treatment, the disease often progressing for years with 
gradual aggravation of the symptoms. The few cases of recovery 
are important. Excision of a portion of the tract of the nerve and 
stretching in others have been found of questionable value. 

ANESTHESIA. 1 

(Gr., a, privative; aiodr/ots, sensibility.) 

In cutaneous anaesthesia one or all of the elements of cutaneous 
sensation may partially or wholly be lost. It may be due to central 
or peripheral causes involving the nerves. 

1 Literature: Impens, TJber Lokalanasthesie (5 papers on Alypin). Dtsch. med. 
Wochenschr., 1905, Nr. 29; Seifert, ibid., 1905, Nr. 34; W. Seeligsohn, 1905, Nr. 
35; E. Stotzer, Dtsch. med. Wochenschr., 1905, Nr. 36; Max Joseph und Joseph 
Kraus, Dtsch. med. Wochenschr., 1905, Nr. 49; Monatshft., 1906, xlii., p. 583; 
Chiene, Observations on the use of Eucaine B and Adrenalin as a means of 
Inducing Local Anaesthesia. Scott, Med. & Surg. J., 1904, p. 215; B. J. D., xvii., 
1905, p. 154. 



PARESTHESIA. 767 

Analgesia, or insensibility to pain, may exist while the tactile 
sense remains unimpaired, or the reverse may be true. Thermo-ances- 
thesia may alone be manifested, and sometimes is limited to heat alone 
or to cold alone. A curious illustration of this occurred in the 
person of a leper, whose hands were in all parts sensitive to the prick 
of a lancet and to contact with heated substances; yet who exposed 
them for hours without protection to an atmospheric temperature of 
ten degrees beiow zero without even slight discomfort. 

The tactile sense is involved more frequently than in hyperes- 
thesia, and usually is absent in all cases of anaesthesia. It, however, 
may be retained unimpaired with loss of one or all of the other ele- 
ments of cutaneous sensation, as sometimes occurs in anaesthetic lep- 
rosy or syringomyelia. The failure to appreciate some one or more 
properties (such as form, size, weight, density, and smoothness or 
roughness) of foreign bodies may be psychical in origin. 

Illustrations of cutaneous anaesthesia are furnished in the anaes- 
thetic patches of leprosy, which may or may not exhibit textural skin- 
changes ; centric and eccentric paralyses ; syphilitic, hysterical, and 
ataxic disorders ; partial or complete anaesthesia of artificial produc- 
tion; the several toxic narcoses; traumatism of nerves by pressure, 
wound, or contusion; the local anaesthesia induced by cold, frigorific 
mixtures, and substances capable of benumbing the sensitiveness of 
the skin; coma, of whatever origin; and a number of idiopathic 
cutaneous disorders, including several of the atrophies, scleroderma, 
and morphcea. 

The substances chiefly employed for the production of local anaes- 
thesia are ice, ethyl chlorid, ethyl bromid, methyl chlorid, eucain B, 
adrenalin, and alypin. 

PARESTHESIA. 

In paraesthesia there is a perversion of sensibility, as a result of 
which a given stimulus produces a sensation different from that which 
it would produce in health. One or all of the elements of cutaneous 
sensation may be involved. Contact with a warm object may give a 
sensation of cold or of pain. Derangement of the tactile sense may 
give erroneous impressions of the size, weight, roughness or smooth- 
ness, firmness, or other qualities of an object. Many other perver- 
sions of sensation occur, all dependent upon central or local disorder 
of the nervous system. Sensations may be delayed for some seconds 
after contact, or many persist after the latter has ceased. 

There may be an error of location, as when the patient refers the 
point of contact to the wrong place or to the wrong side. The paraes- 
thesia may be largely or wholly subjective, and frequently gives rise 
to the sensation of heat or cold, formication, tickling, dripping or 
pouring of liquids of various temperatures, etc. 



768 SENSORY DEEMATO-XEUEOSES. 

PRURITUS. 1 

(Lat., prurire, to itch.) 

Symptoms. — Pruritus is a common form of paresthesia which is 
to be distinguished not only from prurigo, a rare disease of the skin 
already described, but also from the symptomatic sensation of itching 
which is occasioned by a number of cutaneous disorders, such as 
eczema, scabies, and the dermatoses produced by pediculi. 

Hebra was first to recognize the independent character of the dis- 
ease here considered ; but it is to be regretted that he did not give to 
it a name distinct from that which is also applied to a symptom com- 
mon to several maladies of the skin. 

Pruritus is characterized by a sensation of itching not produced 
originally by cutaneous lesions. It may be general or be partial. 
In either form it begins usually by a tickling, pricking, crawling, or 
itching sensation in the skin, which solicits the sufferer to rub, press, 
scratch, or otherwise irritate the affected integument. It usually oc- 
curs by accesses in the day or the night, much more often the latter, 
occasionally both ; and these accesses most frequently occur under the 
immediate stimulus of some internal or external cause. Thus, moral 
emotions, a draught of cool air, the warmth perceived when in bed, 
the pressure of clothing, and often the substances applied externally 
with a view to the relief of the pruritus, suffice to determine a crisis. 
However firmly the sufferer may determine to avoid injury to the 
person, in well-marked cases the impulse to scratch becomes well-nigh 
irresistible and in the highest degree tormenting. From the milder, 
the patient will thus frequently be teased to inflict the severer in- 
juries upon the skin. Brushes, combs, coarse cloths, and even metal 
instruments are employed in severe cases for the purpose of assuaging 
temporarily the local distress. 

The objective cutaneous symptoms which may be presented are 
all secondary, and invariably result from self-inflicted injury. In 
some cases they do not appear, the statements of the patient being the 
sole basis for the recognition of the disease. This absence may be the 
consequence of unwonted self-control, or of the mildness of the mal- 
ady, or of the transitory character of the lesions produced. Thus, 
the skin may be reddened during a nocturnal paroxysm under the 
manipulation of the sufferer, and the transitory hyperemia disappear 
in the daytime when the skin is submitted for inspection. Xot rarely 
however, the integument resents the treatment to which it is subjected, 
by displaying wheals, hyperaemic blotches, reddened papules, excor- 
iations, characteristic " scratch-lines," and the minute blood-crusts 
which indicate that the papillary layer of the derma has been reached 
and slightly torn. Dermatitis in varying degrees, and even eczema, 
may result, and still further add to the subjective distress. Skins 
that for years have been the seat of a persistent pruritus leading to 

1 For fuller discussion of the subject and bibliography, see Jacquet, La Pratique 
Dermatologique, iv., p. 341. 



PEUBITUS. 769 

traumatisms of the epidermis frequently show smaller or larger areas 
of deep pigmentation. The lesions may simulate those of persistent 
urticaria or of prurigo. 1 

Neurodermia.— Neurodermia or neurodermatitis is a name given 
by the French to certain cases reported by Leloir and others in which 
a pruritus was followed by a dermatitis not due to traumatism, and 
persisting for considerable periods of time, or until relieved by treat- 
ment directed to the condition of the nervous system. These cases 
are probably due to vasomotor or other neurotic disorders. 

Senile Pruritus is a term often loosely applied to any form of the 
disease occurring in the aged, in whom it is very common. In the 
large majority of cases, however, careful search will disclose causes 
identical with those found earlier in life. Among the most com- 
mon of these causes are: defective digestion, metabolism, assimilation, 
and elimination, with the resulting hepatic, nephritic, circulatory, 
arthritic, and neurotic disorders so frequently seen in those advanced 
in years. Senile pruritus proper is that form of the disease due to 
atrophic and degenerative changes in the skin and other tissues of the 
aged, and is practically remediless. 

Pruritus Hiemalis and ' ' Prairie Itch ' ' are considered at the close 
of the chapter. 

Bath-pruritus. — Stelwagon 2 describes cases in which an attack 
of itching or burning follows a bath. The pruritus lasts from a few 
minutes to an hour or more, and is limited usually to the legs and 
thighs, but may affect other parts of the body. We have seen several 
such cases. A mild degree of pruritus following the bath is not un- 
common in certain individuals with sensitive skins. 

The localized forms of pruritus, albeit the abnormal sensation is 
in them limited to certain regions of the body, may occasion fully as 
much distress as those in which a larger part of the integument is 
affected. They are of more frequent occurrence than the generalized 
forms. Pruritus of the anus, of the scrotum, of the vulva, of the 
vagina, of the scalp, of the nose, of the mouth, of the axillae, are all 
localized forms of the disease, two or more of which may coexist or 
may develop in succession. 

1 Cf. Hartmann, Archiv, 1903, lxiv., p. 381 (bibliography). Also Veiel, Ein 
Fall von Pruritus cutaneus bei Erkrankung der Niere unci Nebenniere, Archiv, 
1906, Ixxx., p. 59. Milian, Uber Pruritus unci Licheniflkation, verbunden mit 
tabes, Annales cles Malad. ven., 1906, i., p. 321, abstr. Monatsh., 1907, xliv., p. 
240. Milian, Le Prurit tabetique, Bull, de la Soe. med. des hop. de Paris, 1907, 
p. 991, abstr. Annales, 1908, s. iv., ix., p. 175. Klein, Zur radicalen Behandlung 
des Pruritus ani, Therapie der Gegenwart, 1905, abstr. CentralbL, 1906, No. 5, p. 
138. Kromayer, Die Behandlung des Pruritus cutaneus, insbesondere des Pruritus 
ani, Dtsch. med. Wochenschr., 1908, No. 2, abstr. Monatsh., 1908, xlvii., p. 117. 
Joseph, Uber Pruritus ani und Orthoformdermatitis, Wien. klin. therap. Wochen- 
schr., 1906, Nr. 8,_ abstr. Monatsh., 1907, xliv., p. 390; CentralbL, 1906, No. 8, 
p. 238. Eobin, Die Behandlung der Pruritusformen inneren Ursprungs, Journ. 
d. pratic, 1907, Nr. 10 ; abstr. Monatsh., 1907, xlv., p. 373. Mitchell, Universal 
itching without skin lesion; hematogenous urobilinuria ; malarial poisoning; pecu- 
liar erythrocytolysis, Am. Jour. Med. Sci., Mar., 1907, p. 440. Ormsby, J. A. 
M. A., 1906, May 26, p. 1595. Kanoky, J. A. M. A., 1907, May 25, p. 1762. 

2 Phila. Med. Jour., 1898, ii., p. 863. 
49 



770 SENSORY DERMATO-NEUROSES. 

Pruritus Narium is a frequent symptom of irritation of the Schnei- 
derian membrane. It is thus a common precursory or an attendant 
phenomenon of rose- or hay-asthma; and in some individuals an- 
nounces the systemic effect after ingestion of opium and its alkaloids. 
It occurs also in children as a result of pediculosis of the scalp. It 
may result, further, from the irritation awakened by intestinal para- 
sites. 

Pruritus Genitalium is often an exceedingly severe and distressing 
affection. As the parts in question are apt to be rubbed and scratched 
in efforts to secure relief of the itching sensation, there may be pro- 
duced orgastic effects and pollutions, the moral results of which are 
degrading. The scrotum, the labia majora and minora, the penis, 
the clitoris, and the adjacent cutaneous and mucous surfaces may be 
the seat of the pruritus. Search should always be made in these 
cases for ascarides of the rectum or of the vagina, for saccharine and 
albuminuric urine, and uterine or ovarian affections. A perverted 
sexual hygiene may lie at the root of these disorders. In severe cases 
the violence with which the parts are attacked suggests frenzy on the 
part of the patient, who at times is never content until the scrotum 
or other parts are bathed in blood. The thickening, erosions, and 
excoriations of the regions attacked are conspicuous features of the 
disease. 

Pruritus Ani and Vulvae are discussed in detail at the close of this 
chapter. 

Pruritus Palmae et Plantae is a rare form of this disorder, in which 
the itching is limited to the palms and soles. It may complicate 
gout, malaria, hyperidrosis, and asthma. 

Pruritus Linguae is reported in a few instances. It usually is 
due to a central neurosis, to glycosuria, or other systemic disease. 

In all severe forms of pruritus cutaneus the general health per- 
ceptibly fails. Whether the prolonged insomnia arises from noc- 
turnal exacerbations to which there are but few exceptions ; or from 
the perversion of nutrition incident to the continuous teasing of the 
nervous system; or yet from the hypochondriacal state into which 
some patients are plunged by their sufferings, such an issue is often 
to be expected. It is, in fact, a complication that may merit, as much 
as the disease itself, the attention of the physician. 

Etiology. — The causes of pruritus are numerous, and the neces- 
sity for the discovery of the particular cause in each patient often 
makes the largest demands upon the practitioner. The disease may 
occur at all periods of life and in both sexes, but its aggravated forms 
are peculiar to middle life and advanced years. It is always second- 
ary to some disturbance of the nervous system. It is frequently the 
symptom of one of several internal disorders, such as malarial af- 
fections, tuberculosis, carcinoma of the viscera, disorders of the liver 
or kidneys (especially jaundice, Bright's disease, and diabetes), and 
disturbances of the alimentary canal, including those due to intestinal 



PRURITUS. 771 

worms, hemorrhoids, and dietetic or medicinal ingesta. It is common 
in the gouty, the rheumatic, the victims of alcoholism and the neu- 
rotic, and undoubtedly is due often to auto-intoxication. It is often 
reflex in character, and may be associated with almost every one of the 
functional, and not a few of the organic, disorders of the uterus and 
ovaries. The same may be said of its dependence upon the genito- 
urinary diseases Of the male sex, including stone in the bladder, stric- 
ture of the urethra, disorders of the testes and epididym.es, and per- 
verted sexual hygiene. Through the reflex sympathy of one part of 
the skin with other regions it is not at all unusual for one point of 
pruritus to be the exciting cause of new foci of the disorder, even at 
some distance from the original seat of itching. A predisposing cause 
may often be found in hyperesthesia either inherited or acquired 
(sometimes as a result of long-continued inflammatory dermatoses, 
such as eczema), as a consequence of which insignificant external 
irritants cause pruritus. Bronson 1 thinks a diminished tactile sense, 
which implies an imperfect conduction of sensory impressions, is 
often a predisposing cause. 

The pruritus of tabetic patients is often characteristic and severe. 
It is more or less related to the severe girdling pain recognized both 
before and during the complete evolution of the disease. 

Lastly, moral emotions of a depressing character play an impor- 
tant part in the etiology of pruritus. Mental distress occasioned by 
bereavement, separation from relatives, misfortune of all sorts, and 
anxieties as to the future, often find physical expression in the disease. 

Pathology.- — The disease is essentially a functional disorder of the 
nerves of sensation supplied to the skin, and of itself is incapable of 
producing objective symptoms. This fact can, in some cases, be clin- 
ically demonstrated, as the seat of the pruritus, even though exhibit- 
ing artificially produced lesions, will, when protected from external 
injury, speedily regain its normal appearance, the pruritus no less 
continuing. It is probable, though not certain, that the nerves also 
in this disease Undergo no structural change, but merely convey to the 
periphery a perverted sensation that is often reflected from some 
centric point of disturbance. 

Diagnosis. — The recognition of general pruritus is usually not 
difficult, though the secondary results of the disease are apt to be less 
characteristic than its early phenomena. The complaint of the pa- 
tient, the absence of cutaneous disease sufficient to explain the symp- 
toms, and especially the discovery of an efficient cause in some visceral 
or systemic disorder, are all significant. 

One of the most constant features of general pruritus is visible 
only when the clothing of the patient is entirely removed. It then 
becomes evident to the eye that the affected regions are, in the order 
of frequency, those most accessible to the hands. The posterior are 
much less involved than the anterior body-surfaces. The small of the 

111 Etiology of Itching," Med. Kecord, 1891, xl., p. 497 (a careful review of 
the subject). 



772 SENSOBT DEEMATO-NEUBOSES. 

back and interscapular regions are usually untouched. The tibial 
regions of the legs and the forearms suffer more than the calves and 
the upper arms. The lower belly and inner faces of the thighs are 
punished more severely than the breast and outer faces of the thighs 
and the hips. The clavicular regions are more excoriated than the 
back of the neck. There is no more diagnostic sign of pruritus than 
this, and it is one too often ignored by the practitioner, who prescribes 
under these circumstances for a " disease of the blood." 

It must be admitted, however, that when the disease is localized 
and complicated, as it frequently is, by an eczema or a dermatitis, 
doubt may arise. Attention should then be paid to the history of the 
disorder, which may reveal the fact that the pruritus preceded for 
some time the cutaneous symptoms, and may disclose even more. In- 
telligent patients will often assure the physician of the real nature of 
the malady, by voluntarily remarking that the skin-symptoms disap- 
pear upon the region that is not scratched, though the pruritus con- 
tinues. In all cases the influence of externally operating agencies 
should carefully be eliminated. 

Prurigo, with its infiltrated skin, its primary papules, and its 
severe itching, beginning in early infancy and commonly persisting 
through life, can scarcely be confounded with pruritus cutaneus. 

Treatment. — The degree of success to be obtained in the treatment 
of pruritus cutaneus is largely proportioned to the skill with which 
the cause of the disease is recognized and remedied. Taking into 
consideration the number of systemic and visceral disorders which 
may in different cases be responsible for the skin-symptoms, it is clear 
that an exhaustive study of the mental and physical history of each 
patient will be essential at the outset of treatment. The cause once 
recognized, the treatment should be directed to the special disorder 
discovered; and this largely requires the skill of the general practi- 
tioner. The gastro-intestinal tract, the kidneys, the liver, the bladder, 
the uterus, the prostate gland, the rectum, and indeed any one of the 
viscera, may require therapeutic management. All internal causes 
of cutaneous irritation should as far as possible be removed, and to 
this end attention should particularly be directed to any medication 
to which the patient may have been subjected, and which may have 
aggravated the complaint, and also to the diet, which should be regu- 
lated in accordance Avith the principles given under Urticaria. 

In atonic conditions strychnine, iron, and other tonics are indi- 
cated. The nutrition of the nerves and of the skin can often be im- 
proved by the judicious use of cod-liver oil and other fats. 

The attempt to relieve pruritus by the internal use of sedatives 
is to be commended only in extreme cases. The narcotics, while 
they may give temporary relief, tend to relax the skin and in the end 
to aggravate the disorder. This is especially true of the preparations 
of opium. The bromides, antipyrin, phenacetin, sulfonal, or even 
chloral may be given for brief periods in extreme cases, but always 
with the understanding that any one of these remedies, after tern- 



PRURITUS. 773 

porary relief, may aggravate the condition for which it was given. 
Furthermore, there are strong reasons for refusing to employ in pru- 
ritic disorders preparations containing opium, cocaine, cannabis in- 
dica, conium, and other drugs intended to relieve the subjective sen- 
sations by internal medication. Many well-nigh incurable cases of 
the " cocaine-habit " have been begotten by treatment of this sort when 
the patient, often a nervous woman with an intolerable pruritus vul- 
vae, is in a condition peculiarly susceptible to the action of remedies 
of this class. The latter should always be regarded as the last resort 
of the practitioner, and a confession of weakness in not discovering 
the special cause effective in the case with which he is for the time 
confronted. 

Cathartics and laxatives and an abundant supply of pure water 
internally, employed as directed for relief of acute eczema, as well as 
diaphoretics and diuretics, are often of value in eliminating toxines 
to which pruritus may be due; in depleting the cutaneous vessels; 
and possibly in a reflex way by diverting irritation to other regions. 
Jaborandi and pilocarpine have thus been employed to advantage. 
In children full doses of quinine sometimes relieve pruritus, while in 
adults large doses of calcium chloride occasionally will accomplish the 
same result. Cannabis Indica and gelsemium at times are effective, 
but should be prescribed with great caution. 

The indications for local treatment are to protect the skin from all 
sources of irritation and to relieve the itching. Hyperesthesia of the 
skin is common in pruritus, either as a predisposing cause or as a re- 
sult of long-continued pruritus. In consequence very slight external 
irritation may suffice greatly to aggravate the itching, and every pre- 
caution should be taken to protect the skin from exposure of all kinds. 
First in importance is the clothing. The garments worn next the 
skin should be of cotton, lisle-thread, linen, or silk, never of wool, 
and the meshes should be filled with an impalpable powder to reduce 
to a minimum the friction of the garments on the skin. All other 
clothing should be as light as possible and yet be warm enough for pro- 
tection. If the patient live in a climate where sudden changes in 
temperature are common, the clothing should be regulated accord- 
ingly. The object is to keep the skin at an even temperature and 
to protect it from sudden changes. In cases in which the pruritus is 
due largely to the hyperesthesia the itching may be entirely relieved 
by dusting the surface with a simple powder and completely covering 
it with a layer of cotton-wool or other protective dressing. 

Hot baths, unless specially indicated, and the too free use of soap 
may render the skin unduly sensitive. The bran, oatmeal, alkaline, 
and other demulcent baths recommended in the chapter on General 
Therapeutics are those most generally useful. After the bath the 
surface should be patted (not rubbed) dry and covered with a dusting 
powder or other selected application. When the skin is free from ex- 
coriations and other lesions the cold douche, alternate hot and cold 
douching or sponging, or even the cold salt-water sponge may be 



774 SENSOET DEEMATO-XEUEOSES. 

used to improve the tone and vigor of the skin. For localized pruri- 
tus hot baths of four or five minutes' duration, followed by drying 
and the immediate application of a protective dressing, are often 
grateful and beneficial. The water should be as hot as can be toler- 
ated, and to it may be added borax or sodium bicarbonate. 

Scratching is a common source of irritation and one that is diffi- 
cult to set aside. Until this is accomplished, however, relief cannot 
be obtained, as wherever the skin is scratched or rubbed there is pro- 
duced a local hyperemia, or even a dermatitis, which adds to the 
cutaneous irritation, not only at the site of the rubbing, but also by 
reflex action in other regions of the body. It is not sufficient to tell 
the patient not to scratch; the surface must be protected by proper 
dressings, and the itching relieved by the use of antipruritics. Bron- 
son suggests that patients be allowed to obtain relief at times by firmly 
pressing upon the surface or by gently drawing over it an oiled or a 
wet cloth. 

The substances which have been employed topically for the relief 
of pruritus cutaneus are almost without number, a fact warranting 
the conclusion, corroborated in every wide experience, that each occa- 
sionally fails to afford the desired relief. That preparation, more- 
over, which is at one time of the highest value, at another period in 
the history of the same case will disappoint. Attempts to secure re- 
lief by such topical applications should, however, always be made, and 
will often be followed by gratifying results. 

The sedative and antipruritic lotions, lead-water, lead and opium 
wash, liniments, and dusting-powders described elsewhere, together 
with their methods of preparation and application, are valuable and 
sufficient in most cases. They may be further modified by the addi- 
tion of substances recommended in the following paragraphs. The 
dusting-powders are of special value in furnishing mechanical pro- 
tection. When a decided antipruritic effect is desired the Anderson, 
or a similar, powder may be used. In some localized forms of pru- 
ritus more complete protection with ointments, pastes, or even the 
glycogelatins, may be secured. 

Of all antipruritics, carbolic acid easily takes first place. In 
most of the lotions recommended above it is used in strength of 1 to 
5 per cent. In oils or liniments it may be used much stronger. 
Bronson uses it even to 25 per cent., stating that it is much more 
slowly absorbed than in aqueous solutions, and therefore less likely 
to produce systemic effects. A favorite formula with him is the fol- 
lowing : 



]J Acid, carbolic, 5j-ij ; 4-8 

Liq. potass., 5j ; 4 

01. lini, 3j; 30 



M. 



It is to be shaken before using, and may be scented with bergamot. 
These stronger preparations of carbolic acid, even in the oils, should 
be used over only small areas, for fear of toxic effects. The possi- 
bility of producing gangrene by the long-continued application of 
even weak solutions of carbolic acid should not be forgotten. 



PRURITUS. 775 

Other remedies that may be used in lotion, oil, liniment, ointment, 
or paste, in strengths varying from 1 to 5 per cent, or more are: 
salicylic acid, hydrocyanic acid, menthol, camphor, thymol, salol, creo- 
sote, chloral, and chloroform. Two or more of these remedies may 
be combined in the same lotion. Morphine, atropine, and cocaine 
may be added to lotions with occasional advantage. 

Ointments and pastes are irritating to many pruritic skins, but 
at times are more acceptable than the lotions and oils. In abnormally 
dry skins and in some cases of bath-pruritus, a simple oiling of the 
skin often gives prompt relief. 

Chloral-camphor, a pungent, syrupy liquid obtained by triturating 
an equal amount of the two substances in fine powder, is an anti- 
pruritic remedy of value in certain cases if applied in a salve contain- 
ing 1 drachm (4.) to the ounce (30.) of salve, and is comparable in 
its action to phenol-camphor, described in the chapter on General 
Therapeutics. Among other remedies occasionally of service are ich- 
thyol, resorcin, and mercuric chloride. Bronson speaks highly of hy- 
drogen peroxide. The preparations of tar are not well tolerated as 
a rule,' but in some instances are exceedingly valuable. The liquid 
preparations are to be preferred. In atonic cases, with diminution of 
the tactile sense, the use of electricity over the spine has been followed 
by good results. 

In senile pruritus the progressive atrophy and degeneration of 
tissues may be checked or retarded by management proper to each 
case. Locally, electricity or hot and cold douches may aid in stimu- 
lating the skin to renewed vigor. Keeping the skin soft with daily 
inunctions of oil or a thin ointment is an effective measure in many 
cases. 

Treatment of the regional forms of pruritus is that above de- 
scribed, with such modifications in the dressings as may be necessi- 
tated by the special location. 

In ano-genital pruritus the hot bath described above at night is 
especially to be recommended. Fissures and areas of infiltration 
may be painted with compound tincture of benzoin or solutions of 
silver nitrate containing gr. x to 3j (0.66-4.) to the ounce. The 
scrotum when attacked usually requires the use of a suspender, or 
suspensory bag, lined with soft lint or with borated cotton, which 
may be covered with a dusting-powder, wetted with a lotion, or 
smeared with an unguent. 

Severe cases of vaginal, scrotal, and anogenital pruritus are best 
relieved by the x-xaj. High frequency currents are recommended by 
some writers. We have found them of less value than the x-ray. 

In the forms of pruritus due to hepatic disorders great relief 
is sometimes secured by surgical intervention. In Kanaky's case a 
cure was affected by removal of a stone from the common duct. 

Lastly, many cases of intractable pruritus are best managed when 
the attention of the patient is diverted from the malady by the dis- 
traction incident to travel, aided by change of scene and climate. 



776 SENSORY DEEMATO-NEUEOSES. 

Prognosis. — Pruritus senilis is usually an intractable disorder, 
and when dependent upon senile alteration of the cutaneous tissues is 
incurable. For all other forms of the disease a prognosis should be 
formulated with reserve. Under the influence of systematic and ap- 
propriate treatment the happiest results are often obtained. Other 
cases, especially those associated with hypochondriasis, may bid defi- 
ance to all medicinal measures. Relapse of the local forms of the 
malady, especially of that of the ano-genital region, is common. In 
many of these patients the treatment serves merely to palliate. 

Pruritus Hiemalis (Prurigo Hyemalis, "Frost Itch," Winter Pru- 
rigo). — Under the first title Duhring 1 described a harsh and pruritic 
condition of the skin, essentially unattended by structural alteration, 
invading all surfaces of the body, but chiefly the inner faces of the 
thighs, the calves of the legs, and the neighborhood of the joints of the 
lower extremities, usually occurring in the autumn and continuing 
until the following spring. It possesses many features in common 
with the forms of pruritus already described, including variability 
in the subjective sensations awakened, nocturnal exacerbation, and 
the absence of primary eruption. The secondary results are also 
similar, being sequels of self-inflicted injury in the form of roughness, 
perifollicular redness and papulation, torn and fractured hairs, excori- 
ations, blood-crusts, and, in severe cases, an induced dermatitis. It 
however, abates in severity with a rise of atmospheric temperature, 
though there is occasionally noted persistence of the distress after 
such weather-changes. The affection, moreover, is one which occurs 
in persons otherwise enjoying perfect health, in those of every social 
grade, irrespective of the character of the clothing worn and of the 
habitual use or the neglect of the bath. It is, without question, a dis- 
ease of northern climates, more particularly of those where the varia- 
tions of temperature between the extremes of the summer and of the 
winter range between — 30° and -4- 100° F. The description by Duh- 
ring presents a picture (with an accuracy verified by clinical ob- 
servation) which justifies the recognition of the disease as a form of 
cutaneous pruritus. Its treatment is that detailed above, the author 
named laying stress upon emollient unguents, glycerin in the form 
of lotion or ointment, and alkaline baths. The dusting-powders, 
when employed after the tepid bath, have proved more serviceable 
than any fat-containing substance. 

Pruritus Ani. 2 — This disorder may be limited to the anus and ano- 
genital regions or be experienced over the neighboring parts (genital 
region, cleft of the nates, buttocks, and upper and inner parts of the 
thighs). It is a disorder of exceeding persistence when not properly 

1 Phila. Med. Times, January 10, 1874. See also a later but independent obser- 
vation by Hutchinson: Lectures on Clinical Surgery, 1878, vol. i., pt. 1, p. 100; and 
Brit. Med. Jour., 1875, ii., p. 773. 

2 Adler, Lewis H., N. Y. & Phila. Med. Jour., lxxxii., 216, July 29 ; Hill, 
Boston Med. et Surg. Journ., 1906. cliv., 581; Eothschuh, Dtseh. med. Wochen., 
1906, xl. ; Bouquet, Eev. Internat. Med. et de Chir., Feb. 10, 1908 ; Dalche, Journ. 
de Med. et Chir., Jan., 1908. 



PEUEITUS. 777 

treated, and accompanied by local distress (itching, burning, etc.) 
of a severe grade. The parts in many cases are so deformed by 
scratching that excoriations, fissures, crusting, induration, pigmen- 
tation, and extensive thickening of the nates, as well as the several 
forms of eczema, may result. 

The most severe types are seen in men, though both sexes are af- 
fected and the subjects are commonly those in middle or later life. 
Klein however reports the case of a twelve year old girl where the 
pruritus was so severe as to require the Pacquelin cautery for relief. 

Etiology. — The causes are numerous including first, the gouty and 
alcoholic states, and afterward in order: superficial ulcers, either 
within the outer sphincter or about the anal orifice ; impaction of 
feces ; proctitis in various grades ; haemorrhoids, internal or external ; 
abrasion, excoriation, or infection of the peri-anal sulci ; chronic pros- 
tatitis; fistula in ano; sexual irregularities; and disease of the kid- 
neys. Account must also be had of the possibility of intestinal worms, 
utero-ovarian disorders in women, and blennorrhagia of the rectum (a 
condition not so rare as is generally believed). Improper treatment 
has much to do with the aggravation of these symptoms. Joseph re- 
ports a severe orthoform dermatitis occurring in a patient affected 
with pruritus ani. 

Treatment. — The local distress is often relieved by the withdrawal 
of the efficient cause as, for example, in the dyspeptic and the gouty ; 
by securing relief from all rectal, urethral, and vaginal disorders ; and 
locally by pencilling all fissures, excoriations, and cracks with nitrate 
of silver. Exception should be made here to the rule with regard to 
the exclusion of tars generally from the treatment of pruritus, as in 
the distressing itching of the scrotum and the anus they are often es- 
sential. The tincture of tar, oil of cade, and oil of white birch will 
here often be needed. In cases of exceptional severity, the hydrate of 
potash in twenty per cent, solution may be rapidly brushed over the 
surface and soothing pomades applied later, as in eczema of the anus 
(q. v.). In all extreme cases radiotherapy, cautiously employed, is 
followed by admirable results. 

Pruritus Vulvae. — This may be a disorder of mild grade or be 
productive of so much torture that after long deprivation from sleep 
and profound agitation of the nervous system, the unfortunate suf- 
ferers have been tempted to commit suicide. 

Symptoms. — Like pruritus ani, that of the vulva may be limited 
to the genital region (mucous, muco-cutaneous, or cutaneous surface 
adjoining the latter, the outer faces of the labia majora, the labio- 
femoral clefts, and the perineum) or it may extend widely over the 
anus and neighboring parts. The tissues, from much scratching 
and rubbing, are usually tumid and dry rather than moist, are red- 
dened in various grades, and often excoriated, crusted, torn, and in 
extreme cases affected with marked deformity. All the muco-cu- 
taneous tissues, the labia minora, clitoris,' and vaginal membrane 
adjacent may be swollen several dimensions beyond the normal. 



778 SENSOEY DEEMATO-NEUEOSES. 

Etiology. — The causes of pruritus ani are here also effective, in- 
cluding especially utero-vaginal discharges, fissures of the os tincae fol- 
lowing child-birth, and a long list of disorders peculiarly effective in 
the case of women, hysteria, neurasthenia, grief, unhappiness in the 
marriage state, carcinoma of the uterus, and as in Dalche's case, 
kraurosis vulvae. Glycosuria is a common cause. 

Treatment. — The treatment involves chiefly the removal of the 
cause. Important considerations are the securing of -normal urine, 
of daily alvine evacuations; great caution respecting the diet and 
mode of living; absolute cleanliness; and copious vaginal douches con- 
taining either a weak alkali or an aseptic solution such as two per 
cent, of acetate of lead, creolin, or carbolic acid. 

In some cases the ointments are more valuable, one part of car- 
bolic acid, for example, in twenty of benzoated oxid of zinc ointment; 
or what is often preferable, salicylic acid one part, to thirty of Hebra's 
white diachylon salve (q. v.) ; other remedies suggested are one part 
of the bichloride of mercury in five hundred of the emulsion of bitter 
almonds (Skene) ; one part of chloroform, and one of dilute hydro- 
cyanic acid to twenty five of olive oil ; one part of chloral-camphor 
(q. v.) with thirty of vaseline and ten per cent, solutions of argenti 
nitras. 

For pruritus of the vulva Wiltshire 1 recommends decoctions of 
almond-meal, marshmallow, slippery-elm, and rice ; and in case of 
failure of the later, an infusion of tobacco 2 ounces (60.) to the pint 
(480.). Vaginal injections of hot water and tampons or cocoa-but- 
ter suppositories medicated with opium, belladonna, or carbolic acid, 
are also available. Mercuric chloride lotions (gr. -|-j to q] [0.016- 
0.06 to 30.] ) are recommended by many writers. 

Iodoform, oleate and muriate of cocaine, the latter in from 2 to 4 
per cent, solutions; 1 ounce (30.) of the fluid extract of coca, to 2 or 
4 (60.-120.) of water; and linseed oil (especially for pruritus ani), 
are also recommended. 

Jullien recommends in pruritus of the vulva : 

]£ Zinc, oxid., 

Acid, salicylic, 
Glycerin., 
Sig. Apply as required. 

Cheron, in pruritus of the vulva attending the menopause, has 
successfully used : 

I£ Veratria?, gr. iij ; |20 

Axung., fjj 30 1 M. 

He also administers in pill-form K20 grain of veratria rubbed up with 
licorice. Another useful formula is : 

£ Acid, tannic. 3j; 1|33 

Spts. vin. rectify \ .. e -- 1 _. 

Glycerin., / aa ^ ss ' aa 15 ' 

Aq. dest., ad f §iv; ad 120| M. 
Sig. Apply morning and evening on a rag. 

1 Brit. Med. Jour., 1881, i., p. 327. 



5vj; 


24 


gr. xv ; 


1 


5vj; 


24 



PRURITUS. 779 

On account of the peculiar predispositions of the sex, anodyne 
preparations are attended with danger as regards the future habits of 
the patients and should be used with caution. 

The surgical treatment of pruritus vulvae may involve complete ab- 
lation of the external genitalia. 1 Sir Charles Ball 2 produces anaes- 
thesia of the peri-anal region by dissecting away the skin in an oval 
about the anus and replacing the flaps after the dissection. 

Prairie Itch. — -This is a popular term applied largely in the West- 
ern, Northwestern, and Southern States of America to a cutaneous 
affection productive of itching sensations. It is supposed to be the 
disorder popularly described also as the " Texas Mange/' " Ohio 
Scratches/' "Swamp Itch," "Lumberman's Itch," etc. A parasitic 
origin has been claimed for it by several observers who also insist 
upon its contagious character and its curability by parasiticides. 

Personal experience has led to the conviction that these terms are 
loosely applied to a group of cutaneous symptoms of diverse origin. 
The most frequent by far is a pruritus, of the kind described above 
as pruritus hiemalis, occurring in the autumn, winter, or spring of 
the year, and aggravated by the coarse and cheaply dyed woollen un- 
der-garments of the poor and hard-working inhabitants of lumber- 
camps, mining-districts, etc. With these causes in full operation, 
there is often aggravation after swallowing drugs for relief of the 
pruritus, based upon the idea of " purifying the blood." 

With these pruritic cases occur those of undoubted scabies, for 
the study of which the reader is referred to the chapter devoted to that 
subject. The proportion between the purely pruritic and parasitic 
cases of this class cannot definitely be determined. It probably varies 
in different places and seasons, the proportion of cases of scabies in- 
creasing in the lumber-camps when they are reinforced by newly 
arrived immigrants infested with acari. It decreases to probably not 
more than from 1 to 2 per cent, of all skin-diseases in the interior vil- 
lages and towns of the West and Northwest where there has been no 
immigration for some length of time, and where, after the first onset 
of sharply cold weather in the autumn, a large part of the inhabitants 
suffer from pruritic sensations in various degrees. 

A review of the somewhat scanty literature of this subject 3 sug- 
gests the conclusion that the disorder popularly designated as " prairie 
itch," etc., is far more rare in Europe than in America. It is pos- 
sible that the situation of those parts of the United States where this 
group of skin-affections seems to prevail (at a great distance from 
proximity to the seashore, and still further separated from the Gulf- 

1 Cf. 111. Med. Journ., 1905, p. 45. (Howard Kelly's and Borke's method.) 

2 Brit. Med. Jour., 1905, Jan. 21, p. 13. 

3 See two papers by the author, entitled " On the Affections of the Skin In- 
duced by Temperature-variations in Cold Weather," Chicago Med. Jour, and 
Exam., 1885, Hi., p. 187, and 1886, liii., p. 116. Obersteiner: Wien. med. 
Wchnschrft., 1884, No. 16. Brodie: Peninsular Jour. Med., 1853-54, i., p. 506. 
Jones: Kansas City Med. Index, 1886, with views of several Western physicians. 
Clark: Med. Age, 1886. Payne: Brit. Med. Jour., 1887, i., p. 985. Corlett, J. C. 
D., 1894, xii., p. 457, and J. A. M. A., 1902, xxxix., p. 1583. 



780 SENSOEY DEEMATO-NEUEOSES. 

stream) may play an important part in the extraordinary sensitiveness 
of the skin to climatic changes. Certain it is that a great number 
of these affections are entirely relieved by removal to a suitable cli- 
mate, more particularly to one of the Eastern. Southern, or extreme 
Western States. 

Treatment.— The therapy of this affection is that of pruritus, al- 
ready described, save where a parasite is recognized as the efficient 
cause, as in cases of scabies. 

Prognosis. — The prognosis is favorable, though the disease is at 
times intractable, persisting or recurring with repeated thermometric 
variations until the warm season is at hand. 



CLASS VIII. 
PARASITIC AFFECTIONS. 



The disorders due to invasion of the skin by parasites possess 
many features in common with those already described. In them, 
as in others, are observed the hypersemic and exudative processes 
which result in surface-lesions of similar type and career. They 
differ, however, from other affections of the integument in that they 
are all induced by parasites of either vegetable or animal origin; 
and are, as a consequence, commonly characterized by certain special 
features. They involve the skin and its appendages, their symptoms 
being at times displayed chiefly in the integument proper, and at 
other times in one or more of the cutaneous appendages, according 
to the mode of propagation and attack, peculiar in each case to the 
parasite present. They are all in different degrees contagious ; and, 
being induced by local and tangible causes, are usually relieved by 
external treatment. Their importance in cutaneous medicine rests 
not only upon the facts named above, but also upon the too general 
misconception regarding their nature, since there are many patients 
treated by internal remedies ingested vainly for long periods of time, 
who suffer from parasitic disorders often remediable by very simple 
local measures. 

It should not be forgotten, however, that, distinct though these 
maladies be in an etiological sense, they are yet often practically com- 
mingled with others. Thus, an eczematous scalp in a child may by 
accident become the habitat of lice; and the eczema induced origin- 
ally by the, acarus scabiei may persist long after destruction of the 
parasite. 

The term tinea, derived from a Latin word meaning " a moth or 
worm," has by common consent been adopted as a generic designa- 
tion of the cutaneous disorders induced by the presence of vegetable 
organisms. 

DISORDERS DUE TO VEGETABLE PARASITES. 
TINEA FAVOSA.1 

(Lat., favus, a honeycomb.) 

(Honeycomb Kingworm, Porkigo Favosa, Favus. Fr., Teigne 
Faveuse; Ger., Eebgkind.) 

Symptoms. — Favus affects chiefly the scalp, but it also occurs 
upon the glabrous portions of the skin and upon the nails. In the 
1 For bibliography, see Bodin, La Pratique Dermatologique, ii., p. 617. 
781 



782 



PARASITIC AFFECTIONS. 



former situation it is usually first recognized by the development 
of minute, subepidermic, yellowish or reddish puncta, visible through 
the translucent stratum corneum at the site of implantation of the 
hairs. A circle of delicate vesicles may surround these spots. Punc- 
ture with a needle usually gives exit to puriform matter. In the 
course of a fortnight or more these lesions cover themselves with pin- 
head- to pea-sized and somewhat larger, friable, circular, and elevated 
crusts, having the yellowish tinge of the lemon or of sulphur, and a 
concavo-convex shape, with the free concave face of the disk exposed. 

Fig. 151. 




Copyright 1900 by G. H. Fox. 
Favus capitis. (From G. H. Fox's Atlas of Skin Diseases.) 

At the centre of the umbilication thus presented to the eye one or sev- 
eral hairs usually make exit to the surface. The inferior surface of 
this disk, or scutulum, rests upon the scalp, which is either moist 
and deprived over a circumscribed area of its epidermis, or is smooth, 
dry, reddened, and tender. When the crust is removed by traction 
upon the hairs or otherwise a minute cup-shaped depression is left at 
the point where the lowest level of the favus crust was in intimate con- 
nection with the epidermis. 



PLATE XLV 









1 ' 


• M 
















■: 








$k 


*k^ 


-.j**^^ 


"1 




**- 1!k^ 


,._>■: 


jg 




">• - ,-4^ 




. 




v . 




.„ >:* 




sskssS^*^^' '- -> ~^B BM 




,-.<* 








I 




Ew^fe^ "• • 'V "^-^r 




■J 




Stes* J^iiix^-^.* -<-«^^B 


b^BHh 


'*: 




'']■,' 




HV 




iifflS^^*^3^ p s^^^M^K 




^1 




sBEf^^^v^bssiEf^sM 








E^ff^|i*ll 








B 1 ' m 


K * 






Wm^M 


HKy 






«HK/v v -''^ ,?^l 








■ 


]tg 






Js!- 


£&?'■.''■ 








K- ByS 
















,' ' 






— ' 







Copyright, 1900, G. H. Fox. From G. H. Fox's At'.as of Skin Diseases. 

Favus Corporis. 



PLATE XLVI 




Favus Corporis. (James Dunn.) 

Generalized distribution. 



TINEA FAVOSA. 783 

The subsequent features of the crusts, the hairs, and the scalp 
are subject to variation. The crusts may acquire a brownish or a 
greenish tinge by admixture with dirt or with dried pus ; may coalesce 
or may, by gradual desiccation, exchange the yellowish hue for the 
dirty-whitish shade of old mortar, a substance which they then re- 
semble in dryness and friability (Favus squamosum). The hairs in- 
vaded both in the sheath and shaft may lose their lustre; become 
fragile ; appear as fractured relics of longer filaments ; readily be ex- 
tracted from their follicles; and finally be shed, leaving hair-sacs 
destined to atrophy and incapable of reproducing a pilary growth. 
The scalp may first be the seat of an extensive hyperemia or exuda- 
tion going on to the formation of pus, when the fungus is a source of 
acute irritation in consequence of its active development. Later, 
when its destructive work may be said to have been accomplished, 
the scalp-surface is bald, irregularly atrophied, or disfigured with 
cicatrices, which at first are of a deep-red color, but which gradually 
fade, while here and there remain tufts of hair that have survived 
the attack. 

The lesions may be discrete or be confluent, and may vary in 
either case. Occasionally but a few small and ill-developed crusts 
form upon the surface. The entire scalp is not often covered with a 
confluent favus-crust. The disease is usually chronic in its course. 
Untreated, it may undergo spontaneous involution after total destruc- 
tion of all hairs and production of general follicular atrophy, but this 
is rare. It may last for fifteen or twenty years, and even longer. 
It is often accompanied by adenopathy. 

The disease usually awakens a noteworthy degree of itching, and, 
as a result, it is not rare to find the favus-crusts torn and broken 
by the comb or the nails. 

The yellowish disks of the disease occur also in typical develop- 
ment, though more rarely, upon the surface of the face (including 
the bearded cheeks, lips, and chin), and upon the trunk and ex- 
tremities. Fox, of New York, has photographed a patient's knee 
which was covered on its extensor aspect with favus-crusts. 

When the nails are invaded, light or deep-yellowish, circum- 
scribed spots become visible through the nail structure, and by ex- 
tension of these, in consequence of the growth of the parasite, the 
nail-tissue may be thickened, irregularly split, laminated, separated 
from its matrix, or atrophied. The complication is rare, and is sup- 
posed to be due to transfer of the parasite from the scalp to the 
hands in the act of scratching. When it exists the epidermis fring- 
ing the nail is usually also involved. 

Upon the so-called " non-hairy " portions of the body favus occurs 
in the same forms as elsewhere, the localities in the order of fre- 
quency being those most exposed to the hands charged with the para- 
site, or to other sources of the disease, viz., the hands (chiefiy the 
backs and nails), the upper and lower extremities, and the shoulders. 
It is a striking fact that favus may exist for years on the scalp with- 



784 PARASITIC AFFECTIONS. 

out spreading. At a single clinic we have exhibited five patients 
affected with favus, all scalp-cases, the eldest, a male, twenty-five 
years of age, who had suffered from the disease for twenty years 
without occurrence of the lesions elsewhere. 

In favus of the body-surface, outside the scalp, there is often a 
resemblance to ringworm in the production of circular patches with 
an active border made up of vesicles or of papules, which may have 
a favus scutulum as a centre ; or several of these cups may irregu- 
larly be spread over circles of scaling patches. In these cases there 
is often an acuity of symptoms not observed in scalp-cases and coin- 
cident gastro-intestinal signs of irritation, vomiting, etc., which Kun- 
drat believes may originate in favus of the mucous surfaces of the 
oesophagus and gastro-intestinal tract. 

The odor of fully developed favus is so characteristic that by it 
alone a diagnosis has been established. It is usually compared to the 
odor of mice ; also to that of the urine of cats. It should not be 
confounded with the peculiarly disgusting odor of neglected scalps 
affected with lice or covered with pustules and filth. The disease not 
infrequently coexists with other cutaneous, parasitic, and non-parasi- 
tic diseases, as, for example, seborrhoea, eczema, and tinea tonsurans. 
Favus of the Nail (Favic Onychomycosis).- — (See chapter devoted 
to Disease of the Nail.) 

Etiology. — Favus is practically always produced by the presence 
and development of the vegetable organism which is named after its 
discoverer, the achorion Schonlcinii (Fig. 153). * The disease is 
contagious simply because the parasite which produces it is capable 
of transmission from man to man, as also from animals to man, and 
vice versa. It is often conveyed to man from mice, cats, dogs, rabbits, 
fowls, and ponies ; but when derived from the lower animals is most 
often transmitted from mice to cats and 
FlG - 152 - from cats to man. It shares with other 

diseases originating from vegetable para- 
sites the peculiarity of attacking certain 
individuals specially predisposed to 
such invasion, either by reason of phys- 
ical peculiarities of organization or be- 
cause of accidental and fortuitous cir- 
cumstances. It is most common from 
infancy to the thirtieth year of life. It 
is less common in the United States, 
Austria, and England than in France, 
Scotland, and Poland. It is said by 

Culture of Achorion of Schoenlein. -,-> » , i j • r ,\ , ' 

iMeu-durx.) .Bergeron- to be a disease 01 the country, 

while tinea trichophytina prevails in the 

cities. This statement is corroborated by general experience. Favus 

^abouraud, Brit. Med. Jour., 1908, Oct. 10, pp. 1089, 1094. The author de- 
scribes here three species of favus fuugi, and states that 99 per cent, of all cases 
are due to the variety known as the achorion Schonleinii. 

2 Etude sur la Geographie et la Prophylaxie des Teignes, Paris, 1865. 




TINEA FAVOSA. 



785 



is more common in public than in private practice, and the larger num- 
ber of clinical patients with f avus come to the city from the country. 




Achorion Schoenleinii: a, spores; 6, e, sporophores. (After Coenil and Ranvibe.) 



Evidences of contagion are exhibited in those cases in which sev- 
eral members of the same household are affected with the disease ; 
but in other cases the absence of a history of contagion after exposure 
indicates the relative difficulty experienced in propagating the con- 
tagious element in the case of favus. Thus, one individual exposed 
among a dozen who are diseased will fail to exhibit f avus-crusts ; 
and the latter by no means form in all situations of the same body 
where the fungus can be discovered by the microscope. Aubert, 1 in- 
deed, presents an argument in favor of the production of the disease 
by traumatism, the resulting wounds, excoriations, etc., becoming 
by accident the seat of the disease. It is not very rarely discovered 
under poultices and fomentations. 

Occasionally favus occurs in special localities with such devel- 
opment among men and the inferior animals as to constitute an 
epidemic. Girard 2 reports thus the simultaneous existence of the dis- 
ease among sixteen cows and four children in the village of ISTantoin, 
in France. It is propagated also upon the skin of rats and mice, 
from which it is transmitted to man, often through the medium of the 
domesticated cat and dog. 

Pathology. — Under the microscope the fungus is readily recog- 
nized in the root-sheaths, the bulbs, and the shafts of the hairy fila- 
ments near the scalp. At a distance of about two inches from the 
bulb the parasite ceases to appear in the tissue of the hair. It is also 
seen upon the free surface of the skin. The favus-crust, softened by 
the addition of a 10 per cent, solution of potassium hydroxide, may 
be placed upon a glass slide over which a cover slip is placed and 
after allowing it to clear for 5 minutes it may be studied without 
other preparation. The hairs may be examined in the same manner 

1 "Bole de Traumatism dans l'Etiologie de la Teigne faveuse," Annales, 1881, 
s. ii., ii., p. 289. 

2 Lyon med., 1880, xxxv., p. 547. 

50 



786 PARASITIC AFFECTIONS. 

or they may be stained by the methods given for staining the ring- 
worm fungi. Under a good one-fourth- or one-sixth-inch objective 
the vegetation is seen to be composed of intricate masses of mycelium 
and spores in great quantity. 

Quincke 1 attempted to distinguish between three varieties of the 
favus fungus, designated respectively as a, (3, and y. Elsenberg, 
Krai, Pick, Unna, and others have, however, arrived at different con- 
clusions upon the same subject, some recognizing but two of Quincke's 
forms; others, two separate forms not corresponding with the a, /?, 
or y form of Quincke; and still others, corresponding with none of 
those previously described. The majority of observers agree that 
there is but one achorion fungus, displaying itself in several forms 
both under the microscope and clinically, all differences being due 
to accidental influences (varying amount of heat, moisture, and 
friction in the involved surface). 

The threads of the fungus usually preponderate, and appear as 
narrow, flattened, ramifying, short or elongated, linear cells or tubes, 
which may be simple and empty, or be divided more or less regularly 
by transverse partition-walls, transforming the longer and simple 
into shorter and compound cells. The latter often contain in their 
cavities sporules clinging to either side, in which case the mycelial 
threads are termed sporophores. These sporules are the vegetative 
part of the cryptogamous fungus, and develop by multiple subdivision 
into cells, which may also themselves similarly increase in number, or 
by the production, at the terminal extremities of certain mycelial 
threads, of spores or conidia. The conidia are encapsulated or are 
strung like beads upon a necklace, and they appear as round, oval- 
shaped, angular, or very irregularly contoured bodies, often provided 
with partition-walls like mycelium constituting thus compound cells. 
At the same time an amorphous granular matter can usually be dis- 
tinguished in the mass of the fungus. The hyphse vary in width 
from 0.0023 to 0.0030 mm. ; and the spores from 0.0023 to 0.0052 
mm. 

Examination of the invaded scalp reveals, according to Unna, 2 
the presence of the fungus at the lower border of the upper three- 
fourths of the root-sheaths, where chains of conidia appear among 
the histological elements. His view is that the cuticle of the hair 
offers a relative resistance to the growth of the vegetation ; that the lat- 
ter first penetrates the stratum corneum and the follicular orifice, and 
then stretches, upon the one hand, into the cortex and medulla through 
the cuticle of the hair; and, on the other hand, passes to the inner 
root-sheaths, the outer remaining always intact. In the epidermis the 
fungus is found chiefly between the superficial and deep portions of 
the stratum corneum. The superior pars vascularis of the corium 
exhibits enlarged vessels surrounded by inflammatory elements. 

When the nail is involved the parasite may be recognized in the 

1 Monatshefte, 1889, viii., p. 49. 
3 Vierteljahr., vii., p. 170. 



TINEA FAVOSA. 787 

debris produced by scraping the nail-substance; often also in the 
epidermis bordering the nail. The fungus exhibits here the same 
microscopical features as upon the scalp, though in consequence of 
the denser structure of the nail-substance its vegetation is usually 
less luxuriant. 

Diagnosis. — The clinical recognition of favus is based upon the 
presence of the characteristic, yellowish, cup-shaped crusts, which in 
all typical cases are isolated, each pierced by a pilary filament and 
each situated in a well-marked depression of the surface of the scalp. 
In the disseminated form the disks of conglomerated scutella with de- 
fined and frequently festooned edges, friable, yellowish or yellowish 
white in color, and greatly differing as to their bulk and contour, are 
commonly suggestive of the nature of the disorder. In yet other 
irregularly formed crusts the affected area seems to be covered with 
a plaster-like mass irregularly distributed and of uneven thickness 
over an enormous patch of disease which may be practically coexten- 
sive with the entire scalp-surface. Incidentally there may be a his- 
tory of contagion and a peculiar odor emanating from the scalp. The 
secondary effects upon the hairs, hair-follicles, and skin are also, 
when present, significant. In cases of long duration the atrophy, 
scar formation, and permanent baldness are characteristic. White, 
of Boston, in an essay on the " Vegetable Parasites, and Diseases 
caused by their Growth upon Man," calls attention to the stage in 
which the disease is likely to be mistaken for ringworm. It exists 
before the formation of the crust, and may be characterized by hy- 
peremia, vesiculation, or papulation, often unnoticed beneath the 
hairs of the scalp. In doubtful cases the microscope will usually 
establish the diagnosis, though Bodin, Morris, Sabouraud, and other 
observers think it is not always possible to draw a sharp line between 
favus and ringworm, and that cases occur in which it is impossible — ■ 
with the means now at our disposal — to make a differential diagnosis 
with precision. 1 

Aubert, 2 in the absence of the clinical features named above, lays 
stress upon an intense redness of the scalp where the hairs have been 
cut and the crusts removed, this color being limited to the portions 
attacked by the disease. The hairs also, as a result of disintegration 
of their elements are infiltrated with air, and look opaque and 
black by transmitted light; by reflected light they appear polished 
and stratified, as if constituted of layers of tissue. It should not be 
forgotten that in exceptional cases favus-crusts coexist upon the body 
with other diseases of prior or of subsequent origin, as indicated. 
The disease should not be confounded with seborrhoea, pustular ec- 
zema, or psoriasis of the scalp, none of which exhibits the special fea- 
tures of a parasitic fungus. 

Treatment. — The first indication in the treatment of favus is to 

1 For literature of this subject, see Mewborn, J. C. D., 1903, xxi., p. 11 (illus- 
trations and bibliography), and the references tabulated with the introductory- 
paragraphs on Eingworm. 

2 Annales, 1881, s. ii., ii., p. 34. 



788 PARASITIC AFFECTIONS. 

cleanse the affected surface from all crusts and scales that may be 
present. For this purpose the scalp (if this be, for example, the 
affected part) is first shorn of its hair with scissors, and is then thor- 
oughly soaked with olive-, cod-liver, or other oil, or with glycerin. 
After this treatment all the crusts are scraped away with a spatula, 
and the scalp is washed clean with hot water and soap, spirit of green 
soap being here preferably used. The scalp should then again be 
anointed with oil or be covered with an emollient poultice. Once 
thoroughly cleansed by repeated soakings with oil and by ablutions, 
it is necessary to resort either to the topical employment of parasiti- 
cides (agents capable of destroying the fungus) or to epilation (ex- 
traction of the hairs). Often both measures are required. Without 
further treatment the scalp, however completely freed from all evi- 
dences of the disease, will not fail to show fresh f avus-crusts in a fort- 
night or somewhat longer time. 

Epilation is practiced with the aid of epilating-forceps. These 
forceps should be constructed with an easy spring that will not tire 
the fingers of the operator ; with blades that are sufficiently broad to 
grasp a few hairs at once ; and with smooth or but slightly serrated 
faces of the blades, as otherwise the hair is liable to fracture in the 
grasp of the instrument. The surface to be operated upon should 
previously be anointed with vaselin or with olive-oil, and the hairs 
entirely be removed, a sufficient number, covering a definite space, 
upon successive days. 

The tediousness of this process has led to several devices by which 
it is sought to do away with its necessity. Originally the " calotte " 
was employed for the removal of the hairs ; it was made by smearing 
a disk of leather with pitch, and applying it over the scalp. When 
the calotte was subsequently removed by a brisk twitch with the 
hand the hairs which adhered were forcibly uprooted en masse; those 
remaining being adherent in their sacs in consequence of the fact that 
they had not been invaded by the fungus. As a substitute for this 
procedure, Bulkley 1 employed adhesive masses or sticks, which can 
be melted and made to adhere at once to large numbers of the hairs. 
When cold they can be withdrawn from the surface with the hairs at- 
tached. These sticks are from two to three inches in length, and from 
one-fourth to three-fourths of an inch in diameter. The hair is first 
clipped so as to be about one-eighth of an inch in length. The end 
of the stick is then heated in an alcoholic flame, and quickly placed 
upon the scalp. It is thus left in place until cold, and is removed 
by bending it over and drawing upon the hairs successively with 
slight rotation. When free it is found thickly set with the extracted 
filaments, which may be burned off in the alcohol flame, thus destroy- 
ing both the hairs and any adherent fungous masses. The stick is 
then carefully wiped clean with paper, after which it is again ready 
for use. The formula for the mass of which these sticks are com- 
posed is as follows: 

1( 'Favus and its Treatment bv a New Method of Depilation," Arch, of Derm., 
1881, vii., p. 1496. 



TINEA FAVOSA. 789 

$ Cerse flavse, 5iij ; 12 

Laccas in tubulis, 5iv; 16 

Kesinse, 3vj ; 24 

Pieia Burgundicse, 3xj ; 44 

Gummi dammar., 5J SS 5 45 ^- 

Inasmuch as the disease is so frequently intractable and resist- 
ent to the usual methods of treatment and its tendency is to per- 
manently destroy the hair and produce atrophy of the scalp, radio- 
therapy is advised above other methods of treatment. Complete 
epilation may be produced by this method with safety and with return 
of the hair thus removed, and with the majority of the cases com- 
plete eradication of the disease. 

The parasiticides in greatest favor are : corrosive sublimate in so- 
lution in the strength of from 1 to 4 grains (0.066-0.266) to the ounce 
(30.) ; formalin (1 to 4 per cent.) ; sodium hyposulphite in saturated 
solution ; pure or diluted sulphurous acid ; spirit of green soap ; chry- 
sarobin, pyrogallol, tar, croton-oil ; boric, carbolic, and salicylic acids ; 
petroleum, chloroform, ether, creosote, and oil of cloves. The addi- 
tion of acetic acid to liquid applications, or washing the surface with 
vinegar immediately before applying the parasiticide, favors penetra- 
tion of the remedy. Ointments are also useful containing mercury 
(citrine ointment, yellow sulphate, or white precipitate), naphtol, ben- 
zol, thymol, sulphur, pyrogallol, salicylic and carbolic acids. Chry- 
sarobin is effective in an ointment, though objectionable on account 
of the staining of the scalp, and, almost inevitably, of the face also. 
Lenzberg 1 generates sulphur-fumes in a dish of red-hot coals attached 
to a frame (made of wood or of pasteboard) close to the head of the 
patient. By means of a paper cap the fumes are collected and re- 
tained (from five to ten minutes) in contact with the patient's hair. 
During ten years' trial of this plan he has never been compelled to 
resort to epilation. 

One or more of the methods may be needed, either at the same 
time or by repetition or alternation, until the fungus is entirely de- 
stroyed, the requisite period usually extending over three months. 
Treatment should then be discontinued in order to test the result by 
observation. If, in the course of a fortnight or more, a relapse occurs, 
treatment is to be promptly renewed. Upon the non-hairy portions 
of the body parasiticides thoroughly applied usually insure radical re- 
lief. "When the nail is involved, it should be cut short and carefully 
scraped or be softened by repeated applications of a strongly alkaline 
lotion, after which a parasiticide may be employed in ointment or 
lotion. 

In general, it may be remarked that patients long affected with 
rebellious f avus may need a roborant course of treatment and nutri- 
tious diet. Cleanliness here, as in all the parasitic disorders, is im- 
portant. As adjuvants in the treatment of the scalp and nails it is 
well to remember that continuous applications of a parasiticide are 

*Der prakt. Arzt., February, 1881. 



790 PARASITIC AFFECTIONS. 

aided by caps or cots of impermeable material superimposed upon 
rags saturated with the medicament employed. For use in this man- 
ner, and especially for the nails, Sabouraud recommends a solution 
containing 1 gramme of iodine and 2 grammes of potassium iodide in 
a litre of distilled water. 1 

Prognosis. — The prognosis is generally favorable to the ultimate 
termination of the disease in all cases; for even the most rebellious 
and untreated forms are relieved when the hair-follicles atrophy. 
Upon the non-hairy portions of the body the disorder is rarely severe 
if promptly and efficiently treated. Upon the scalp the prognosis is 
proportioned to the extent, severity, and period of prior invasion of the 
disease. Early and vigorous treatment of the scalp in healthy chil- 
dren is usually followed by satisfactory results. In long-neglected 
subjects of the disorder the result may be a remediless and character- 
istic baldness, the affected surface being provided with scanty wisps 
of stunted and uncolored hairs. Neglect, filth, and systemic mal- 
nutrition are the most unfavorable elements in any case. 

TINEA TRICHOPHYTINA. 

(Gr., Opi(- f hair; <j>vr6v, a vegetation.) 

(Ringworm.) 

Ringworm is a disease of the hairs and hair-follicles of the scalp 
and the beard, as also of the non-hairy portions of the body. In each 
case it is produced by the presence of a vegetable fungus. Until re- 
cently all forms of ringworm, both of the hairy and non-hairy portions 
of the body, were supposed to be produced by a single fungus, the 
trichophyton. In 1891 Furthmann and ISTeebe first advanced the 
idea that there were two or more fungi responsible for the various 
manifestations of the disease. Within the last few years a number 
of investigators, headed by Sabouraud, in a series of researches, have 
more definitely settled the etiological value of these fungi. 2 There 
are at least two distinct and unrelated forms capable of producing 
the appearances classed as ringworm : the Microsporon Audouini, or 
small-spored fungus, and the Trichophyton, or large-spored fungus. 

1 See paragraphs at the close of the chapter on Ringworm. 

2 Sabouraud, Les Trichophyties humaines, with Atlas, Paris, 1894 ; Diagnostic et 
traitement de la pelade et des teignes de 1 'enfant, Paris, 1905; La Pratique Der- 
matologique, iv., p. 467; Adamson, B. J. D., 1895, vii., pp. "201, 238 and 373; 
Morris, Practitioner, Aug., 1895; Ringworm and the Trichophyton, London, 1896; 
Fox and Blaxall, B. J. D., 1896, viii., pp. 241, 291 and 337, and Brit. Med. Jour., 
1899, ii., p. 1529; Transactions of Third International Congress of Dermatology, 
London, Aug. 4 to 8, 1896, including papers by Sabouraud, Rosenbach, and Morris; 
Rosenbach, ' ' Ueber die tief eren eiternden Schimmelerkrankungen der Haut, ' ' Wies- 
baden, 1894; Leslie Roberts, Brit. Therap. Jour., Sept. 29, 1894, and Jour. Path, 
and Bact., Aug., 1895. (This observer classifies the fungi according to their ability 
to digest horny tissues.) M. Fadyen, Jour. Path, and Bact., April, 1895; Jamie- 
son, Brit. Med. Jour., Aug. 20, 1893; Bodin, Des Teignes tondantes du eheval et 
leur inoculations humaines, Paris, 1896; Mibelli, Annales, 1895, s. iii., vi., p. 733; 
Charles J. White, J. C. D., 1899, xvii., p. 1; Ceresole, Annales, 1906, s. iv., vii., 
p. 743. 



TINEA TBICHOPHYTINA. 791 

Of the latter, several varieties are recognized. The microsporon 
appears under the microscope chiefly in the form of a large number 
of round spores, irregularly grouped or massed about the follicular 
portion of the hair. Mycelial threads, large and branching, are also 
seen, chiefly within the hair. The sheath of spores surrounding the 
hair is often continued upward about the latter for one-sixteenth or 
one eighth of an inch above its exit from the follicle, and in this situa- 
tion can be recognized by the unaided eye as a whitish or grayish coat- 
ing of the hair. 

The mycelial threads of the microsporon are all within the hair 
proper, and after repeatedly dividing and subdividing they terminate 
on the outer surface of the shaft in fine filaments, at the extremities 
of which are the spores, which in this fungus are external. In 
France the microsporon is responsible for about 60 per cent, of all 
cases of ringworm of the scalp in children. The fungus is not found 
in ringworm of the beard or of the body except in the form of small 
irregularly outlined, slightly reddened, and furfuraceous patches, oc- 
curring on the face and neck in children having ringworm of the 
scalp ; occasionally on the skin of adults who come in contact with 
such children. Such lesions of the skin do not at all resemble ordi- 
nary ringworm, as their outlines are irregular and ill defined, and 
they rarely persist for more than a few days at a time. In France 
the microsporon is rarely if ever found in kerion. 

The trichophyton is composed of spores which vary greatly in size, 
but which, as a rule, are considerably larger than those of the micro- 
sporon. They are frequently cuboidal, oval, or irregularly rounded ; 
but their chief characteristic lies in their arrangement in lines or chains 
extending up and down the hair-shaft. The mycelium is found with- 
out but never within the hairs. The trichophyton occurs in three va- 
rieties: the endothrix, in which the spores occur wholly within; the 
ectothrix, in which the spores are distributed wholly without ; and the 
endo-ectothrix, in which the spores are partly within and partly with- 
out the hair. The endothrix, like the microsporon, is found chiefly 
in ringworm of the scalp of children, though it also may produce tran- 
sient, inconspicuous, irregular, furfuraceous, and slightly reddened 
patches on the face and neck of children affected with this form of 
ringworm. On the scalp the endothrix produces lesions which are 
often distinctly different from those caused by the microsporon. 
These differences are noted in the clinical description of tinea tonsur- 
ans. The ectothrix and the endo-ectothrix apparently are derived 
either directly or indirectly from the domestic animals, and are re- 
sponsible for ringworm of the body, of the beard, and of all sup- 
purating forms of the disease. 1 By means of culture-experiments 
a number of subvarieties of the trichophyton are differentiated, many 
of which, however, are not generally accepted. These varied appear- 
ances are looked upon by some as the result largely or wholly of dif- 

1 Bodin reports four cases of superficial sycosis due to endothrix alone (Annales, 
1900, s. iv., i., p. 1205). 



792 PARASITIC AFFECTIONS. 

ferences in the media and circumstances of cultivation. It is well 
known that slight modifications of the culture-media produce marked 
changes in the character of a fungus-growth. Under certain con- 
ditions the trichophytons may assume forms indistinguishable under 
the microscope from those of tinea favosa. 1 

In London, Morris, Fox, Adamson, and others find that the micro- 
sporon is responsible for more than 90 per cent, of all cases of ring- 
worm of the scalp in children, and that it also occurs in some cases of 
ringworm of the body, and even in some of the suppurating forms of 
the disease, as kerion. The trichophyton is comparatively rare in 
London. On the other hand, Mibelli states that the microsporon is 
almost unknown in some parts of Italy, and it would seem to be 
equally rare in some portions of Germany. In Boston Dr. Charles 
J. White found the microsporon in 88 per cent, of scalp cases; Cor- 
lett 2 in 90 per cent, of such cases in Cleveland ; and G. A. Wende 3 in 
89 out of 90 cases in Buffalo. In Scotland Walker 4 found it in 18 
out of 20 of Jamieson's cases. A similar preponderance of the micro- 
sporon in ringworm of the scalp in children has been our experience in 
Chicago. The different varieties of these fungi seem to have a defi- 
nite geographical distribution. 

To prepare a hair for examination, it may be placed between a 
slide and cover-glass in a solution of potassium hydroxide. Sabour- 
aud uses a 25 to 40 per cent, solution, which is admirable for rapid 
work, but which quickly disintegrates the hair. Adamson employs a 
5 or 10 per cent, solution, which clears the hair slowly in the course 
of one or several hours. By making frequent examinations of the 
specimen the observer can arrest the destructive action of the solution 
at any stage desired, and thus better preserve the relative position of 
the fungus to the hair. Many attempts have been made to stain the 
fungi, which unfortunately show an affinity for the same stains as does 
the cortical layer of the hair. A satisfactory method has been devised 
by Morris and his laboratory assistant, Calhoun. It is a modification 
of the Gram and Weigert stain for bacilli, and gives good results. 
The hair is first washed with ether to remove fatty debris ; it is then 
put for one or two minutes in the Gram iodine solution, and after 
drying is stained for from one to five minutes in gentian- violet and 
anilin-water. It is again dried and treated for a minute or two with 
the iodine solution, and for an equal length of time in anilin-oil con- 
taining pure iodine, after which it is cleared with anilin-oil, washed 
in xylol, and mounted in Canada balsam. Coarse, dark hairs and 
spores within the hairs require more time for staining than do fine, 
light-colored hairs and the fungus-elements situated without the hair. 

While microscopical examination will often suffice to distinguish 
the microsporon from the trichophyton, or even for recognition of 
some of the varieties of the latter, the finer — and often disputed — 

1 Cf. Mewborn, J. C. D., 1903, xxi., p. 11 (bibliography). 

2 Corlett, J. A. M. A., March 18, 1899. 

3 Wende, G-. A., ibid. 

* Walker Norman, An Introduction to Dermatology, 1899, p. 150. 



TINEA CIBCINATA. 793 

points of difference can be appreciated only by means of culture- 
experiments, the details of which require fuller description than can 
here be given. 

Recent studies of the ringworm fungus, 1 though interesting from 
an etiological standpoint, have added little knowledge of practical 
value in treatment of the disease, nor have they furnished a basis for 
a new scientific classification of the different forms of ringworm. 

As the several regions of the body, when invaded by the parasite, 
display lesions which are more or less peculiar to itself, it is useful to 
consider each separately. Ringworm of the body is, therefore, desig- 
nated Tinea Circinataj of the scalp, Tinea Tonsurans; of the beard, 
Tinea Sycosis. 

Tinea Circinata. 

(Herpes Tonsurans, Ringworm oe the Body. Ger., Scheerende 
Flechte; Fr., Herpes circine, Tricophytie.) 

Symptoms. — Ringworm of the body displays different symptoms 
according to the temperature in which the vegetation flourishes and 
the various external irritants to which the skin where it has once been 
implanted is subjected. 

The macular form of the disease is characterized by the occurrence 
of one or of several pea- to large coin-sized, circumscribed, reddish 
circles, usually paling under pressure, often at the general level of the 
integument, occasionally slightly raised above it, forming then a flat- 
tened disk. The centre of the circle may be paler, or indeed to the 
naked eye be unaffected, transforming the patch to an annular lesion, 
from which circumstance it originally received the name " ringworm." 
It develops within certain limits, rarely exceeding five or six inches 
in diameter, by peripheral extension ; and is usually characterized at 
the outer border by slight, whitish, furfur aceous desquamation. This 
form of lesion is usually seen upon exposed surfaces of the body where 
there is less heat, moisture, and friction than upon other parts, as, 
for example, the forehead and neck in moderate atmospheric tempera- 
tures. From it may be developed the other forms described below. 
The disease may recur within the peripheral border ; in this way 
occasionally two, three, or more concentric rings or parallel bands of 
crescentic outline may be visible in a single patch of disease. Fre- 
quently a tendency to a peculiar formation, often that of concentric 
circles, is found in every patch existing at the same time in a given 
case. It is possible that the various types are produced by different 
species of the fungus. The subjective sensations are a trifling degree 
of itching or of burning. Should these rings extend to the beard or 
the scalp, the circinate may coexist with the other varieties of the 
disease. 

The vesicular lesions of ringworm appear as such at the onset, or 

^Sabouraud, Brit. Med. Jour., 1908, Oct. 8, pp. 1089, 1094. This article de- 
scribes the bacteriology of the fungi and the author classifies the fungi according 
to cultural findings. 



794 PARASITIC AFFECTIONS. 

they rise from the macular lesions described above. In the former 
case pin-point-sized, transitory, and superficial vesicles or vesico-pap- 
ules spring from a central point or focus, or speedily shrivel until 
they are represented merely by minute, whitish, branny scales. To 
these lesions others succeed, always at the periphery, and to these 
again yet others, the rosy or the reddened base on which they rest 

Fig. 154. 




Copyright 1900 by G. H. Fox. 

Trichophytosis corporis. (From Dr. G. H. Fox's Atlas of Skin Diseases.) 

being sometimes slightly in advance toward the outlying skin. The 
enlarging circlets of disease proceed in their course to an evolution 
similar to that observed in the macular forms. The difference, due 
to a more active development of the fungus, is noted not merely in the 
type of the lesion, but also in the slightly exaggerated pruritic sensa- 
tions that are awakened. Rarely, both of the forms described are pre- 
sented, with acute symptoms and extensive development, in multiple 
patches spreading over the face, neck, trunk, and extremities, accom- 
panied by a slight febrile movement and moderate tumefaction of the 
affected surfaces. As a rule, the eruption is trifling, and may, in- 
deed, be limited to a single ring, or to a few circlets about the neck, 
terminating in the branny desquamation described ; but in the severer 
forms the evolution of the disease may persist for months ; and. crusts 
form, the fall of which leaves annular pigmentations of temporary 
duration. 

The papular and rare pustular forms of the disease observe the 
same peculiarities with respect to the clearing of the centre, the an- 
nular appearance of the advancing area of involvement, and the pro- 
duction finally of scales and crusts. They represent, however, either 
a much more luxuriant vegetation of the fungus, or the irritation of 
the affected part by friction and heat, or, what is probable, the cooper- 
ation of the two. They are, hence, most commonly observed upon the 
back, the belly, the intermammary and inframammary regions, and 
the inner faces of the thighs and arms, in which localities they occa- 
sionally occur with chronic manifestations. The papules are light- 
er dull-reddish, pinhead-sized and larger, solid elevations, roundish, 



TINEA CIBCINATA. 795 

oval-shaped, irregular, or confluent, forming eventually bean- to 
coin-sized raised disks with a pale, exfoliating, or actively inflamed 
centre, the so-called nummular erythema, or discoid trichophy- 
tic erythema of French authors. Some of the cases of conglomerate 
or agminate folliculitis are due to the trichophyton. 1 The itching in 
these forms is sometimes severe; and the process may display central 
recrudescence, as noted above. Pustules found at the periphery 
have the size and distribution of the other lesions described. They 
represent merely an aggravated exudative process awakened by the 
fungus and tfce scratching incident to the pruritic sensations excited. 
Eczema Marginatum, Tinea Trichophytina Cruris. — Partly be- 
cause of the controversy which the subject aroused, special attention 
was once directed to this variant of the disease which Hebra was first 
to describe. It is most marked upon those portions of the body which 
come in contact with the saddle when a rider is mounted on a horse — 
that is, the perineum and the inner faces of the thighs, the region 
marked by the reinforcing patch in the trousers of the cavalryman. 
The disease, as encountered here, occurs in both sexes. It is charac- 
terized by extensive exudation in bright or lurid patches, with a very 
distinctly defined, raised border, showing a sharp contrast with the 
healthy skin beyond, from which peculiarity it has its name. It may 
extend laterally over the groins, upward over the pubes, and backward 
over the sacrum, being generally defined at the periphery by a crescen- 
tic outline. The centre may be paler and less involved, or actively 
irritated, while the periphery still extends in one or more annular 
festoons down the inner side of the thigh or upward over the regions 
indicated. The itching is severe ; the course of the disease is obstin- 
ate, persistent, and subject in a remarkable degree to relapse in the 
same locality. The fungus is always present, whether occurring as 
a cause or an epiphenomenon of the disorder. The disease was 
rightly named by Hebra, and it deserves special recognition under 
whatever title it may be classified. It is a true eczema, with special 
features, complicated by the development of the trichophyton, and, 
as is now well known, often by other representatives of the " der- 
matological flora." It is aggravated by heat, the moisture of sweat, 
and the friction of apposed surfaces of the skin in contact with each 
other and the clothing. After detecting the fungus in scales scraped 
from. the surfaces thus involved, one is always in such cases impressed 
with the characteristic clinical peculiarities of the disease. It is usu- 
ally of symmetrical distribution, due to the circumstances of its de- 
velopment, and in this respect differs from the other manifestations of 
the disease. The condition may occur in milder or even severe forms 
in the axilla, or about the breasts of women, or about the umbilicus. 
In such cases it is indistinguishable clinically from a disorder de- 
scribed by Vidal under the title circinate and marginate pityriasis 
{pityriasis circine et margine), which he regards as due to micro- 
sporon anomoeon, or dispar. 

1 Cf. Schamberg, J. C. D., 1902, xx., p. 410 (review of published eases) . 



796 



PABASITIC AFFECTIONS. 



Tinea Tonsurans. 

(RlNGWORM OF THE ScALP, HERPES TONSURANS, TmEA ToNDENS. 

Ger., Scheerende Flechte ; Fr., Teigne Tondante.) 

Ringworm of the scalp is a disease chiefly of children, and occurs 
most frequently among those congregated in public institutions. The 
gregarious habits of children and the frequency and intimate charac- 
ter of contacts in their amusements and studies greatly increase the 
chances of contagion when one of their number is affected with ring- 
worm of the scalp. As a consequence, the early recognition and re- 
lief of the disease furnish problems among the most imperious pre- 
sented to the general practitioner as well as to the dermatologist. 
Important considerations relating to the segregation and education 
of children are related to the question of treatment. Nor should the 
physician, examining and giving advice about the scalp of a number 
of children, forget that his hands may transmit the disease to those 
as yet unaffected. 

Symptoms. — The differences to be particularly noted between ring- 
worm of the body and ringworm of the scalp depend largely upon the 
fact that in the latter the fungus makes its way to the hair-follicles 
and there finds the nutriment for its multiplication and development. 
The symptoms usually first observed are circumscribed, small coin- 

Fig. 155. 




Copyright 1900 by G. H. Fox. 
Trichophytosis capitis. (From Dr. G. H. Fox's Atlas of Skin Diseases.) 

sized, roundish patches upon the scalp, wholly or partly covered with 
minute, whitish, slate-colored, grayish, or dirty-yellowish scales. 
Sometimes the formation of the scales can be observed as they develop 
upon a hypersemic and reddened area. Still more rarely, pin-point- 



TINEA TONSURANS. 797 

sized, transitory vesicles or pustules precede. The hairs upon such 
a patch seem irregularly clipped short near the surface or, as it is fre- 
quently styled, "nibbled" off, thus producing the effect of partial 
baldness in the involved area. Among them may often be found lus- 
treless, dry, long, and fragile hairs, which break upon, slight traction 
or flexion. The patches may increase in number and spread indivi- 
dually in area until, in the course of weeks or months, the entire 
scalp is invaded. In the older patches young and downy hairs may 
here and there be seen, pushing up the stumps left by those that have 
fallen. One or more of various phases of the disease may be pre- 
sented in its subsequent evolution. Thus, a single patch may extend 
to the size of that of a large coin or of the palm, and the disease be 
throughout limited to that area. Again, as set forth above, almost 
the entire scalp may be covered with relatively small or enlarging 
patches, or, even without the occurrence of any distinct patch, isolated 
hairs or tufts of hairs here and there over the entire scalp may ex- 
hibit evidence of impairment. The hairs, instead of " starting " 
from the patch, may be twisted, imbricated, or matted, and be covered 
with grayish scales. The disease may be acute or be chronic in its 
course. Instead of assuming the dry and squamous type described, 
acute and exudative symptoms may develop, in which event the 
rare vesicular lesions are succeeded by the exudation of a gummy sec- 
cretion and the formation of crusts. Lastly, there may be produced 
the variety known as '"kerion," which is described below. 

Pruritus, in various grades of severity, though usually mild, is in- 
duced by the disease ; and often the patches are altered in appearance 
by the traumatisms produced by the finger-nails and the comb. When 
the scalp is very generally invaded by the squamous «form of the dis- 
order its appearance is very similar to that noted in diffuse sebor- 
rhea, chronic eczema, and psoriasis of the scalp, except that the hairs 
are less pasted to the surface; are more lustreless, friable, and con- 
torted in shape; and much more often are represented by stubble or 
stumps. The disease may occur coincidently with ringworm of the 
body, and indeed at times there may be detected a ring, half of which 
on the neck presents the typical aspect of tinea circinata, and the other 
half involving the scalp exhibits the features here described. 

Stowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and 
others, have recorded cases in which the disease coexisted with alo- 
pecia areata. Geber asserts that after exfoliation of patches of ring- 
worm the scalp may, in cases, become absolutely bald, smooth, and 
glossy. This condition may exist from the beginning in the Bald 
Tinea Tonsurans of Liveing, which is often mistaken for alopecia 
areata, an error readily corrected by the recognition of scaling patches 
with hairs exhibiting under the microscope evidences of the existence 
of the fungus. It is to be remembered that in all such persistent 
scaling patches left after treated or untreated ringworm of the scalp 
the possibility of contagion is not averted. 

1 Lancet, 1881, i., p. 326. 
- Ibid., 1880, i., p. 425. 



798 PABASITIC AFFECTIONS. 

The Disseminated Ringworm of Alder Smith affects isolated hairs 
or small groups of hairs scattered over the scalp, a broken stump, 
or a group, or a relatively small number, of lustreless, dry, and friable 
hairs furnishing the only evidence of the disease. 

Ringworm, produced by the microsporon Audouini can often be 
distinguished clinically from that produced by the trichophyton. In 
the former the patches are single or few in number, are rounded or 
oval in outline, may be of considerable size, are usually slightly red- 
dened and furfuraceous, and are more or less covered with hairs 
which are lustreless, dirty looking, broken off at irregular distances 
from the surface, and easily epilated between the thumb and finger 
in considerable numbers. Moreover, in this form a grayish or whitish 
sheath (composed of spores) is seen encircling each hair and extend- 
ing from one to three millimetres above its exit from the follicle. 
In patches of ringworm produced by the trichophyton the patches 
are much more numerous, but are very small and irregular in 
outline, and instead of being covered by hairs and broken stumps 
of hairs, usually show a number of black dots at the mouths of 
the follicles caused by the breaking of the hair at or beneath the 
surface of the skin. In this latter form of ringworm the scalp 
itself is usually normal or nearly so, scaling not being usual ; and, 
instead of forming patches, the disease may affect isolated hairs 
or small groups of hairs. The disseminated ringworm and the bald 
tinea tonsurans mentioned above are probably produced by the tricho- 
phyton, and not by the small-spored fungus. It is undoubtedly true 
that the clinical differences mentioned above can be noted in some 
cases, and the diagnosis made at once from a simple inspection of the 
affected areas. In the majority of cases, however, the clinical fea- 
tures are not sharply marked, and the diagnosis must rest upon micro- 
scopical examination, or even upon culture-experiments. 

Lastly, it is to be noted that in tinea tonsurans at times the efforts 
of nature are successful in securing spontaneous relief. With the 
defluvium capillitii and exfoliating epidermal plates the fungus may 
finally be removed ; the resulting alopecia be followed by a growth of 
healthy pilary filaments; and, even though years be required for this 
long process, in the end no trace of the disease be discernible. 

Tinea Kerion (Kerion Celsi, from xqpiou, a honey-comb). — 
The occurrence of active and usually circumscribed inflammation in 
a portion of the scalp affected with ringworm is at times followed by 
certain peculiar features. This complication of ringworm was recog- 
nized early in the history of medicine by Celsus, whose name has since 
been associated with its lesions. Tilbury Fox, in 1866, was first to 
recognize its identity with tinea tonsurans ; and it has since been 
the subject of a number of papers by Tanturri, Maiocchi, Schilling, 
Barduzzi, Auspitz, and Wilson. In the United States, Atkinson 1 has 
made it the subject of a memoir. 

The symptoms are the occurrence of acute inflammation, usually 

a Arch. of Derm., 1881, vii., p. 47. 



TINEA SYCOSIS. 7!) 9 

circumscribed, though occasionally diffuse, 1 in a portion of the scalp, 
where a tumor forms which may project to a considerable height above 
the general level. In time the appearance presented is suggestive of 
anthrax benigna, since from the tumid orifices of numerous distended 
follicles a viscid, semitransparent, puriform fluid exudes. The latter 
is characteristic. The hairs loosen and fall. When the view of the 
lesion is not obscured by the pilary growth it appears as a flattened 
hen's-egg- to turkey' s-egg-sized, boggy, semiglobular tumor, its surface 
congested, reddened, glazed, and often exhibiting other evidences of 
inflammation, with split-pea-sized, pustule-like lesions distributed 
over its surface, or, when these have ruptured, exhibiting the gaping 
apertures described above, from which a gummy secretion is poured 
in varying quantities. Modification of this condition occurs, such 
as the production of a true subcutaneous abscess with fistulous sin- 
uses. The' sensations awakened are usually painful ; the course of 
the disease is chronic. It may begin with the usual symptoms of 
ringworm of the head, though often there is no history of the latter. 
The complication is a rare one. 

The parasite may and may not be found in patches of kerion, ac- 
cording to the acuity of the present or the precedent inflammatory 
process. If the latter be of high grade, and suppuration result, the 
fungus is destroyed, a result the attainment of which has been at- 
tempted in the production of " artificial kerion " by means of croton- 
oil for the relief of tinea tonsurans. In the earlier stages represented 
by deep-seated follicular inflammation, with pustulation of the hair- 
shafts, the latter may be seen microscopically to be invaded with 
spores. 

Tinea Ciliokum. — Ringworm of the eyelashes is a rare condi- 
tion. It may occur in connection with the disease in the beard or on 
the glabrous skin. In the recorded cases the lashes were broken off 
short and usually concealed by a scale. The lids were red and 
swollen. 

Tinea Sycosis; Hyphogenous Sycosis. 

(Tinea Bauble, Sycosis Parasitica, Mentagra Parasitica, Ring- 
worm of the Beard, "Barbers' Itch." Ger., Parasitare 
Bartfinne; Fr., Trichophytie Sycosiqtje.) 

Symptoms. — The disease is best studied at its onset in the beard of 
a blonde subject with relatively fine, downy hairs, where are presented 
the typical features of tinea circinata, ringworm of the body. One 
or several, reddish, pea- to small-coin-sized rinsrs become visible, with 
pin-point-sized vesicles, branny scales, and often, indeed, no other 
lesion save a hypersemic, scarcely elevated margin at the periphery. 
The hairs over the patch may be fragile, and clusters of pilary fila- 
ments here and there betray evidences of change. With proper treat- 
ment the disorder may not progress beyond this point. 

!Wallis, J. C. T>., 1905 : xxiii., pp. 428, 431. Ten cases with multiple small 
kerion are described occurring in girls from eight to seventeen years of age. 



800 



PARASITIC AFFECTIONS. 



In some cases the very slight degree of itching awakened by the 
process just described may be intensified, and large plaques form, a 
portion of which may extend from the region of the beard over the 
face and neck, or vice versa. When fully developed a phlegmonous 
disorder is produced which bears some analogy to the kerion just de- 
scribed, and which may so actively progress that it is first seen in 
typical development. The skin is congested and reddened, with sub- 
epidermic (or debris of ruptured) pustules at the orifice of the pilary 
follicles, and it is studded irregularly with firm, pea- to nut-sized pap- 
ules and tubercles. The tubercles are usually aggregated in masses 
or lumps which involve the skin and subcutaneous tissue, and they 
are firm, often tender and painful, rarely boggy and furuncular. 
When pierced they give exit to a characteristic, muciform, gluey, yel- 
lowish, and sticky fluid, puriform yet differing from pure pus, that 
rapidly dries into crusts. These composite lesions are usually circum- 
scribed in a given area of involvement, very rarely covering the region 
of the beard in symmetrical disposition, more often limited to one 
cheek or to the cheek and chin. 

Fig. 156. 




Tinea sycosis. (Mewboen.) 



The hairs in the invaded region are involved as in ringworm of 
the scalp. These filaments break near the surface of the integument, 
leaving ragged stumps ; or they spontaneously fall after being loosened 
in their follicles. The ease with which they may be epilated is one 



TINEA SYCOSIS. 801 

of the most characteristic features of the disease ; they are slipped 
out of their follicles as readily as if they had been oiled ; or, as Ander- 
son writes, " as easily as a pin can be pulled out of a pin-cushion." 
They are then often whitish because enveloped in the fungus pro- 
ducing the disease. In either event the resulting gradual thinning 
or removal of the hairs renders the disease of the surface more con- 




Tinea sycosis. 

spicuous and deforming. At the edge of a patch thus exposed, de- 
formed, lustreless, contorted, flattened, twisted, or split hairs may 
be found. Occasionally the features of the patch are changed in con- 
sequence of the unusual degree of suppuration excited. In this case 
the pustules burst and their contents concrete into dry crusts about 
the stumps of shafts of surviving hairs, from which circumstance the 
disease has received its name (sycosis, gvx ov i a ^S)- Rarely, a con- 
glomerate crust covers the entire region with an excoriated, inflamed, 
and secreting surface beneath. 

Formidable cases of tinea sycosis have occurred in the persons of 
farmers, where the disease was long untreated and unrecognized. 
Some severe types of the disease have been produced after shearing 
sheep having diseased pelts. In these cases the cheeks, lips, and 
chin are the seat of nut- to fist-sized and larger cutaneous and subcu- 
taneous, soft, boggy, and pus-filled tumors, accompanied by excessive 
soreness of the entire throat and neck, the hair falling from the fol- 
licles in large masses, and as if lubricated to facilitate their escape. 

51 



802 PARASITIC AFFECTIONS. 

Etiology. — Tinea circinata is caused by the presence of the para- 
site, though the parasitic invasion may be an accident of other cuta- 
neous disorders. In the majority of cases one or the other of the trich- 
ophytons is the causative factor, only occasionally is it produced by 
the microsporon. The trichophyton was first discovered in 1844 by 
Gruby; though Malmsten, whose name is often associated with that 
of the fungus, became identified with its recognition by his observa- 
tions during the succeeding year. As a contagious disease it ranks 
higher in the scale than favus, being much more readily communi- 
cated, and, as a result, much more common. Occurring upon the 
non-hairy portions of the body, it is often spontaneously removed by 
the desquamative process which it excites in the skin. 

Though the fungus is the essential cause of the disease, its develop- 
ment is greatly favored or retarded by external influences. Atten- 
tion has already been called to its luxuriance under the influence of 
heat and moisture. It is, therefore, much more severe and rebellious 
to treatment in tropical countries. It occasionally occurs in epidemic 
forms. Thus, Gerlier 1 gives the details of such an epidemic in Fer- 
ney Voltaire, where twenty-six cases of the disease came under his 
observation. In some of these instances the lesions were pustular, 
in others tuberculo-pustular. Aggravated forms of the disease often 
originate in the lower animals, the severest and most rebellious types 
being derived often from the horse. Tinea circinata occurs much 
more frequently in children than in adults, presumably from the rela- 
tively tender condition of the epidermis in these subjects. It is par- 
ticularly liable to occur in men whose skins are especially moistened, 
as in those who work in atmospheres saturated with steam. Several 
members of a single household will often display ringworm of the 
body at the same time, having transmitted it the one to the other. 
The need of an appropriate soil for the germination of the fungus is 
shown by the fact that some individuals are predisposed to its in- 
vasion. It is, however, encountered in both sexes and in all social 
conditions. 

Tinea tonsurans is produced usually by the microsporon Audouini. 
A small per cent, only are due to the trichophytons. (See introduc- 
tory paragraph on Ringworm.) Ringworm is observed frequently in 
children of both sexes, especially in those gathered together in schools 
and public charities, where it may spread very generally from one 
to another, and require months and years for its extermination. It 
is a highly contagious disease, but yet requires unquestionably a suit- 
able soil for its development. White 2 calls attention to the fact that 
when there is ringworm on the face of an adult, even of rebellious 
form, in the course of which the beard may be affected extensively, 
the scalp usually is spared. Ringworm in the scalp of the adult and 
the aged is, indeed, among the rarest of cutaneous accidents. Among 

1 Lyon med., 1881, xxxvi., p. 599, and xxxvii., p. 7. 

2 Loc. cit., Henri Malherde, Jour, des Malad. Cutan. et Syph., 1900, s. v.. xii., 
p. 129; abstr. B. J. D., 1900, xii., p. 306. Eeport of a case with generally dis- 
tributed lesions on the body and scalp due to the microsporon. 



TINEA SYCOSIS. 



803 



the methods of transmission in children are the nse upon the head of 
the unaffected, of brushes, combs, wearing-apparel, sponges, towels, 
etc., which have been employed upon persons exhibiting ringworm of 
the body or the head. It must be remembered that tinea circinata 
may occasionally transmit tinea tonsurans ; and it is by tracing the 
course of the two forms of the disease that the sources of contagion 
can be ascertained in any series of cases. The disease is one rather 
prevailing in cities than in the country ; in this respect it differs from 
favus. 

Tinea sycosis is produced by the ectothrix or enclo-ectothrix va- 
rieties of the trichophyton (see introductory paragraphs on Ring- 
worm). J. C. White, of Boston, has called special attention to the 
frequency of its origin in the barber-shop, a fact which common exper- 
ience verifies. It is usually the irregular visitor to these establish- 
ments who is first to supply the germs of the disease. No individ- 
ual proprietorship in cup, soap, brushes, and razor can secure against 
the danger of infection the person whose razor is drawn over a com- 
mon strop, whose cheek is handled by unwashed fingers which have 
recently been passed over an infected face, or whose beard is combed, 
brushed, or rubbed with the implements and towels in common use at 
these establishments. 

It is difficult to determine the frequency of the disease from sta- 
tistics. The affection is certainly relatively rare, yet more common 



Fig. 158. 




Filaments and spores of the trichophyton from the beard of 
tinea sycosis. 



patient affected with 



than is often supposed to be the case. It is of somewhat irregular 
occurrence, months often passing without a case coming under obser- 
vation, after which several may be noted in rapid succession. 

The disease, being contagious, is one affecting men in all stations 



804 



PABASITIC AFFECTIONS. 



of life, and these usually at a period rather under than over the 
fortieth year. More men with light hair and eyes, and light-brown, 
reddish, or sandy beard are affected than those having darker shades 
of hair and eyes. Morris has called attention to the fact that tinea 
tonsurans 1 occurs more frequently in blonde than in brunette subjects. 
Pathology — The seat of the fungus in tinea circinata is between 
the strata of the epidermis, more particularly in the lower layers of 
the stratum corneum and in the superior layers of the rete. Here 
the trichophyton can be recognized with the microscope, at an early 
stage of the disease, in the form of spores only ; in the course of a few 

Fig. 159. 




Epidermis invaded by trichophyton : a, inferior portion of the stratum corneum ; 
6, superior portion of the rete. Both exhibit long mycelial threads, with a few rami- 
fications and a small number of spores. (Kaposi.) 



weeks exhibiting characteristic mycelium. The latter is much more 
scantily developed than in f avus ; much less branched and articular ; 
and the threads more slender. Like the elements in favus, however, 
these are jointed and divided into compound cells by partition-walls. 
The spores are also often strung like beads on a necklace. The for- 
mer measure 0.0018 to 0.0026 mm. ; and the latter, 0.0021 to 0.0035 
mm. (Duhring). 

After the fungus has found its way to the surface of the skin 
favorable to its development it penetrates the layers of the epidermis 
in every direction from the central point of invasion, the circle thus 
produced being characteristic of many forms in both the higher and 
the lower vegetable life. The irritation excited by the presence of 
this foreign body produces all the subsequent symptoms of a mild 
grade of superficially seated inflammation: erythema, exudation, 
minute vesicles, papules, and, in severe grades, tubercles and pustules, 
lancet, 1881, pp. 164, 241. 



PLATE XLVII 




Portion of a Hair showing the Mierosporon Audouini. 

(From a photomicrograph.) 




Portion of a Hair invaded by the Trichophyton, 
Endo-eetothrix. X BOO. 

a, a, chains of spores in focus; b, a chain situated farther within the hair, and hence not in focus. 
(From a photomicrograph.) 



TINEA TBICHOPHYTINA. 



805 



The desquamative symptoms represent, in a sense, the natural effort 
at relief; this effort, as noted above, being often successful when the 
spores and sporophores are thrown off with the effete, horny plates 
of the epidermis. When the nails are affected the fungus can be dis- 




Hair invaded by the trichophyton. 

covered in detritus of the nail-tissue which has been macerated in 
dilute liquor potassse. Sabouraud states that only the different spe- 
cies of trichophyton, ectothrix pure, or endo-ectothrix, are found in 
ringworm of the glabrous skin and of the nails, though the trichophy- 
ton endothrix and the microsporon Audouini may be found occasion- 

Fig. 161. 




Trichophyton endothrix culture from the scalp. (Mewboen.) 



ally in small, irregular, transient, reddened, slightly furfuraceous 
areas occurring on the face, neck, and other parts of the body during 
the course of ringworm of the scalp. 

Tinea tonsurans is produced in consequence of invasion of the 
scalp and follicles, bulbs, and shafts of the hair by the fungi already 
described. 



806 



PARASITIC AFFECTIONS. 



Under the microscope the hairs are seen to be greatly altered 
in advanced cases (Fig. 160). The bulbs are distorted, misshapen, 
or withered, and often stuffed with spores which greatly predominate 
over the mycelium. At times the base of the bulb will show a brush- 
like expansion, and in this respect resembles the free ends of the 

Fig. 162. 




Culture three weeks old from ringworm of cat contracted from ringworm of 
girl's face. (Mewbokn.) 

stumps of the hairs above, which have a jagged, bristle-like appear- 
ance, from division of the shaft into many filaments between which 
spores in abundance are visible. The shaft is often longitudinally 
split where the parasitic growth has mechanically forced apart 
its elements, and its cuticle may be peeled off or curled above and 

Fig. 163. 




Trichophyton ectothrix culture (rose-pink in color), from a case of tinea sycosis. 
iMewborn.) 



below away from the axis, with spores protruding at such points. 
Conidia can be discovered much further upward along the hair and 
distant from the scalp than in favus; often, indeed, upon its free 
surface. Occasionally a few mycelial threads may be recognized, 



TINEA TBICHOPHYIINA. 



807 



either longitudinally or transversely arranged as regards the axis. 
It is probable, however, that the relative preponderance of spores and 
mycelium in these filaments is determined by the stadium of the dis- 
ease in any given case. In the earlier stages of the affection the elon- 
gated threads may be discovered in larger quantity, and, as they in- 
terfere less with the integrity of the fibrous tissue, the hair usually 
at these times may be extracted from its follicle without fracture. 
Later, the threads disappear, and the conidia are infiltrated through- 
out every portion of the shaft, which then breaks often upon the 
slightest traction. One unaccustomed to microscopical examinations 
with a view to the detection of the parasite should be careful not to 
mistake for these threads the delicate lines which traverse the sur- 
face of the shaft exposed to the objective, and which represent the 
edges of the cuticle of the hair. In doubtful cases the hair should 
be examined in liquor potassse and after staining by the methods 
given in the first pages devoted to the subject of ringworm. The 
scales found upon the affected scalp also exhibit traces of the para- 



Fig. 164. 




Trichophyton ectothrix culture three weeks old from the case of tinea sycosis in 
fig. 156. (Mewboen.) 



site under the microscope, though to a less extent than the invaded 
hairs. In exceptional cases, however, the epidermis of the scalp 
seems to suffer as much as that of the non-hairy portions of the 
body. 

As to the mode of invasion, 1 it is still disputed whether the spores 

1 Annates, May, 1907, p. 326-7; June, 1907, p. 309— Abstr. B. J. D., 1908, 
p. 60. Sabouraud describes in connection with the microsporon an extrapilar 
sheath of spores with an intrapilar mycelium. The fungus proceeds downward 
from the orifice to near the middle of the hair-follicle where it penetrates the 
cuticle and runs parallel in the hair with the long axis of the shaft. The spores 
are produced by the breaking up of the intrapilar and possibly by reproduction of 
the extrapilar mycelium. 



808 PABASITIC AFFECTIOXS. 

find access to the fundus of the follicle between the shaft and the 
follicular wall, or by penetrating the cuticle of the hair-shaft at the 
level of the epidermis. It is possible that invasion may occur in 
both ways. 

Tinea sycosis is essentially a follicular and perifollicular inflam- 
mation induced by the irritative effects of the fungus, precisely as 
in the case of tinea tonsurans. The difference between the clinical 
aspects of the two diseases may be explained by the difference in the 
inflammatory reactions produced by the two parasites causing the dis- 
orders. The trichophyton ectothrix which induces sycosis produces 
moist and actively inflammatory lesions as a rule, while the niicro- 
sporon found in most cases of tinea tonsurans produces dry lesions 
that are only mildly inflammatory. As a result of the induced in- 
flammation, vesicles, pustules, papules, and tubercles are formed, 
while the peri-follicular inflammation may invade all portions of the 
skin and subcutaneous tissues, gluing together the plastic nodules 
formed about the individual hair-sacs into the lumpy masses character- 
istic of the disease. The invasion of the hair follicles and hairs by the 
fungus is accomplished as in the case of ringworm of the scalp. Under 
the microscope spores and mycelium are visible, the former prepon- 
derating at the time when the disease first comes under observation, 
but probably preceded in most cases by abundance of thread-like 
forms. The identity of the disease with some forms of ringworm of 
the body and scalp does not, however, rest merely upon microscopical 
observation, but is demonstrable by established clinical facts. Not 
only may ringworm be seen to spread from the face to the beard, but 
tinea tonsurans and tinea circinata may also transmit tinea sycosis, 
and the reverse. A physician had ringworm of the bearded chin and 
cheek derived from the face of a child under his care. He subse- 
quently gave tinea circinata to his wife, who suffered on the face and 
shoulder, and she, in turn, communicated tinea tonsurans to her 
daughter. Such cases, however, are unusual (see introductory para- 
graphs on Ringworm). 

Diagnosis. — Ringworm of the body is to be distinguished, clinic- 
ally, from eczema, psoriasis, seborrhcea, lupus erythematosus, herpes 
iris, and syphilis. All the varieties of eczema are noted for their 
greater degree of itching and infiltration, their much less defined 
border, coarser scales, decided absence of a circular contour and of a 
history of contagion. Psoriasis does occur in circular and annular 
patches, often with a clear centre and insignificant, subjective sen- 
sations ; but its scales are lustrous and the tissue beneath them readily 
bleeds, showing deeper implication of the skin. The disease is often 
symmetrical in disposition ; occurs by preference upon certain regions 
of the body where ringworm is relatively infrequent ; and its history 
is that of a chronic disorder. Seborrhcea of the skin exhibits greasy 
or fatty crusts, which are never characterized by the peculiarly branny 
scales seen in ringworm of the body. (The distinction between these 
disorders on the scalp is given below.) Lupus erythematosus is often 



TINEA TBICHOPHYTINA. 809 

symmetrical, generally chronic, and is characterized by the develop- 
ment of multiple annular patches, enlarging centrifugally from a 
clearing centre. Herpes iris can be distinguished, first, by its predi- 
lection for the extremities ; second, by the color-variegations which 
it displays and which are never seen in ringworm of the hands. 
Syphilis is multiform in its lesions, usually preceded by a history of 
infection; and its distinctly circular patches, enlarging at the peri- 
phery, all exhibit either atrophic, ulcerative, or distinctly crusted les- 
ions which suffice for diagnostic purposes. 

Pityriasis rosea is not characterized by vesicles ; is often symmet- 
rical in development ; occurs in oval rather than in distinctly circular 
patches; and exhibits a characteristic tawny-yellowish shade of color 
not seen in ringworm. In eczema marginatum the elevated border 
and infiltration of the diseased surface, its situation (groins, armpits, 
pubes, etc.), its curved outlines, and the occurrence of fresh rings 
within the older, point to the nature of the trouble, which is practi- 
cally a coexistence of ringworm and dermatitis. 

But the microscopical discovery of the parasite is the chief, and, 
indeed, the essential, method of diagnosis in tinea circinata. With 
a good fourth- or fifth-inch objective the spores and mycelium are 
readily recognized in the scales scraped from the affected surface and 
moistened with dilute liquor potassse. Care should be had in dis- 
tinguishing the fungous elements from cotton- or wool-fibres, fat- 
globules derived from previously applied unguents for the cure of 
the disease, sebum, pus, and the nuclei of epithelia. All confusion 
of this sort can be avoided by a careful study of the anatomical pe- 
culiarities of the trichophyton, recalling especially the parallelism 
seen in the double contours of the threads, their jointed appearance, 
their contained granules, and the necklace-like or beaded arrange- 
ment of many spores. 

The recognition of a typical patch of ringworm of the head is 
simple. The branny scales, clumps of hairs, and distinct contour 
of the invaded area are always in the highest degree suspicious symp- 
toms. It has been stated, however, that the general development 
of tinea tonsurans over the scalp produces a condition very like that 
seen in other diseases. In this case the microscope must be employed 
for a decision as to the nature of the process. The whole vertex has 
been unnecessarily epilated in seborrhoea sicca when no parasite could 
be found; but in seborrhoea there is usually a symmetry of involve- 
ment which even aggravated cases of ringworm of the head fail to 
assume; and even though pasted down, atrophied, changed in color, 
and loosened in their follicles, the hairs are rarely broken off near the 
scalp in seborrhoea. In seborrhoea, psoriasis, and squamous eczema 
of the scalp there is, moreover, no history of contagion ; the scales are 
in each disease different in color and character; and the hairs in 
the two affections last named are firmly fixed in their follicles, and 
only in severe cases present nutritional changes. The diseases, more- 
over, are usually chronic in their course. In any doubtful case, apart 



810 PAEASITIC AFFECTIONS. 

from microscopical evidence, thorough removal of all scales from the 
scalp by shampooing with green soap and hot water will reveal the 
nature of the disease present. 

Alopecia areata, as has been noted above, may coexist with ring- 
worm, but it is pathologically distinct from it. The patches in the 
first-named disease are uniformly smooth, and the hair falls from 
them en masse without scaling or other traces of previous involve- 
ment of the regions affected. Blackish points or dots may, however, 
be distributed over the areas which characterize this form of alopecia, 
and which certainly constitute suspicious symptoms in any case. In 
this event one may at times be able to pick out with a fine needle 
this blackish point from the patent follicular orifice, and find it to be 
a particle of dust accidentally lodged in the depression. It is not, 
as in comedo, free pigment that has found its way to the surface ; nor, 
as in ringworm, is it the stump of a hair on a level with the surface 
of the scalp. In favus the cup-shaped crust will sooner or later be- 
tray the character of the disease to the naked eye. 

Confirmatory evidence as to the nature of the disease will often be 
furnished by a careful search for the source from which it was de- 
rived; and for obvious reasons this should always be attempted. 
Ringworm of the body occurring upon the individual patient affected 
with tinea tonsurans, or upon other members of the same household, 
and suspicious " mangy " patches upon horses, dogs, cats, rabbits, 
white mice, or other animals with which the child may have been in 
contact, should always receive attention. 

Ringworm of the bearded region is to be differentiated chiefly 
from coccogenous sycosis; and, necessarily, the microscope must be 
employed to settle the question definitely. The diseases, however, 
differ in their clinical features. The coccogenous form always fails 
to exhibit the nodules, tubercles, and composite cutaneous and sub- 
cutaneous agglutinations of the disease produced by the fungus. The 
process in the former is more superficial, and it exhibits to the eye 
a more vivid redness as a result of the cutaneous hyperemia. Ow- 
ing to the same cause, the frequent pus-containing lesions are de- 
veloped and elevated above the general level of the integument ; they 
are less commonly subepidermic crypts filled with characteristic 
mucoid puriform contents. The region of the bearded upper lip, 
so often involved in cases of nasal catarrh, is often spared by the tri- 
chophyton. When this parasite is present the hairs are characteris- 
tically loosened, distorted, and otherwise changed. This condition 
is not seen in the coccogenous disease ; exception, however, in this par- 
ticular is to be noted in some long-standing cases of the latter. When 
the affection has persisted for many years (and one may often see 
patients thus affected) the thinned and starved condition of the pilary 
growth is a striking symptom, the scanty lustreless hairs often scarcely 
sufficing to conceal the deforming redness and pustulation of the sur- 
face from which they spring. The diffuse symmetrical affection of 
the hairy face, extending over both cheeks and chin, is more fre- 



TINEA TBICHOPHYTINA. 811 

quently connected with the presence of pns-cocci. Lastly, the lympho- 
genous, as a rule, is less painful and tender than the other form of 
sycosis, and, furthermore, is, without question, of rarer occurrence. 

With respect to syphilis, it is to be noted that the papular or the 
pustular syphiloderm developed in the region of the beard is, almost 
without exception, to be discovered in other parts of the body, especi- 
ally the scalp. Kingworm of the scalp and the beard existing at the 
same time in one individual is rare. In syphilis there is usually an 
offensive odor to the abundant crusts ; shallow ulcers are also prone 
to form beneath the pustules ; and there is often a history of infection 
or a hint of the nature of the disease in its polymorphic character. 

Eczema of the bearded region may extend to or from other por- 
tions of the face, as in a case in which it sweeps from the ear above. 
The presence of a stalactitic crust depending from the lobe of the ear 
of an affected side would at once furnish a clue to the nature of the 
disease in the beard. In eczema the interfollicular region is invaded, 
not deeply, as in tinea, but superficially, as in coccogenous sycosis. 
The itching is severe; the hairs are not involved; the infiltration is 
diffuse; the outline is indeterminate; and a halo of redness spreads 
from the affected part to the non-hairy surface in the vicinity. 

Treatment. — The indications in the treatment of ringworm of the 
body are the removal of the superficial layers of the epidermis, by 
which means the spores and mycelium are thrown off from the sur- 
face; and, if possible, the simultaneous destruction of the latter. 
Upon the delicate skins of infants and children the simpler remedies 
are first to be employed. Scrubbing each patch with spirit of green 
soap, or merely soap and water, will often suffice for its obliteration. 
The topical application of tincture of iodine is a common and usu- 
ally an effective remedy. Sabouraud 1 states that tincture of iodine 
diluted with five times its volume of alcohol gives better results than 
the pure tincture of iodine. Dilute acetic, boric, and carbolic acids, 
or a 1 to 2 per cent, solution of formalin are available. A solution 
of acetic acid used with or immediately before other parasiticides 
is said to favor penetration of the latter. Morris's solution of thy- 
mol, 2 -J drachm to 2 drachms (2. to 8.) of chloroform and 6 drachms 
(24.) of olive-oil, is equally available. One may also use thymol 
in ointments, \ drachm (2.) to the ounce (30.) of simple un- 
guent, with good effect. Of the mercurials, ammoniated mercury, 
1 scruple (1.33) to the ounce (30.) of ointment; corrosive sublimate, 
1 to 2 grains (0.066-0.133) to the ounce (30.) of solution; and the 
ointment of mercuric nitrate, 1 drachm (4.) to the ounce (30.) of 
vaselin, are valuable. Sulphurous acid, from a freshly opened can, 
and saturated solutions of sodium hyposulphite are as effective as any 
of the parasiticides, and are often used with advantage as lotions, to 
be followed by an appropriate unguent, always providing against 
chemical decomposition of the ingredients of the latter. Sulphur- 

1 Brit. Med. Jour., 1908, Oct. 8, pp. 1089, 1094. 

2 Lancet, 1881, i., pp. 164 and 241. 



812 PARASITIC AFFECTIONS. 

and tar-containing lotions and unguents are useful in more obstinate 
cases. 

Chrysarobin and pyrogallol, in ointment, from 5 to 10 grains 
(0.33-0.66) to the ounce (30.), are brilliantly effective in all these 
cases, subject, however, to the disadvantage incidental to the staining 
and irritative effects they produce. They should be used with cau- 
tion upon the skins of children, and always tentatively at the onset. 
Chrysarobin used in the strength of 1 to 5 per cent, in traumaticin is 
a valuable application and has the advantage of being retained in 
the area applied. In cases of ringworm of the face of male adults, 
close to the beard or the scalp, one may employ these remedies with a 
view to insure non-invasion of the pilary follicles by the fungus, the 
prompt destruction of which may become then a matter of urgency. 
Wilkinson's ointment recommended by Kaposi is also useful in the 
treatment of aggravated forms of ringworm of the body, but it should 
be restricted to such forms. For other and more urgent reasons potas- 
sium hydroxide solutions should be reserved for exceedingly intract- 
able cases. Sometimes a combination of several of the simpler reme- 
dies named above may be serviceable, as in the following formulae : 

I£ Lac. sulphur., 

Sapon. virid. spts., \ 
Lavandul. tr., i 

Glycerin., 



]J Iodin. pur., 

01. picis [sp. gr. 0.853], 
Mix with care, gradually. 

I£ Creasoti, 
01. cadini, 
/Sulphuris prsecip., 
Potass, bicarb., 
Adipis, 

To be used in obstinate ringworm of adults. 

R. W. Taylor applies mercuric chloride, 4 grains to the ounce 
(0.266-30.) in tincture of myrrh. Perry, of California, uses the 
bichloride in one-half the strength last named, dissolved in sulphuric 
ether. Foulis, of Edinburgh, recommends iodine dissolved in oil of 
turpentine or benzin, the fluids named penetrating with greater ease 
than others to the deeper portions of the skin. 

Other articles advised are oleates of mercury and copper, croton- 
oil, glacial acetic acid, cantharidal collodion, petroleum, and pyrolig- 
neous acid (Thomas). 

The thorough application of the remedy selected for use, upon 
the integument freed from scales by scrubbing with soap and water, 
is a matter of importance. When a solution of sodium hyposulphite 
is employed the previous application of vinegar and water by sponging 
renders the agent more effective, for evident chemical reasons. Over- 



5ijss; 




10 




5vj; 




aa 24| 


5ss; 




2| M. 
[Kaposi.] 


yy, 




601 


5J; 




30 1 M. 


TTLxx; 




1 


33 


f 5iij ; 




12 




f 5iij ; 




12 




5j; 




4 




5j; 




30 


M. 




[Van Harl 


ingen.] 



TINEA TBICHOPHYTINA. 813 

treated skins, or those to which too strong a parasiticide has been 
applied, require subsequent relief of the induced irritation by the 
simpler bland dressings. The inert dusting-powders, even when not 
thus indicated, are often useful when there is distinct vesiculation; 
and in simple cases they may be the sole remedies required, as then 
the disease is self-limited in duration. 

The internal treatment of patients affected with ringworm, by 
means of tonics and roborant measures, may be demanded by the sys- 
temic condition, but it has no recognized influence over the disease 
itself. 

When the nails are involved, they should be thoroughly scraped 
and then kept moist by wearing the rubber cots sold for the use of 
sportsmen, fishermen, and others. In this way a partial maceration 
of the nail-substance is secured, and the action of any one of the para- 
siticides named above is greatly aided. One of the solutions most 
useful in the treatment of the nails is that recommended by Sabour- 
aud, containing 1 gramme of iodine and 2 grammes of potassium 
iodide in a litre of distilled water. 

The indication for the relief of the disease in the scalp is the de- 
struction of the parasite ; and there can be no question that this may 
be accomplished in some cases without having recourse to epilation. 
The parasiticides named in connection with ringworm of the body, if 
thoroughly applied in simple cases, after clipping or shaving the hair 
and efficient scrubbing of the patch with spirit of green soap and 
water, will occasionally be followed by permanent relief. Prom- 
inent among these parasiticides may be named formalin (1 to 5 per 
cent, in aqueous solution), pyroligneous acid, sulphurous, acetic, sali- 
cylic, and boric acids, saturated solutions of sodium hyposulphite, 
acetum cantharidis, tincture of iodine ; Crocker's ointment containing 
thymol, 1 part to 4 of salve-base ; Morris's solution of thymol in chloro- 
form and olive-oil (see above) ; and ointments of boric acid and sul- 
phur, of each 1 drachm (4.) to the ounce (30.) of vaselin, and 
chrysarobin, the action of the latter being carefully limited to the 
patch of disease by the aid of a skull-cap. 

Epilation, however, is a valuable, and often an essential, method 
of treating the disease, and it may be practised as recommended when 
considering the treatment of favus. The scalp in each case should 
first be oiled, and be cleansed by the soap-shampoo, and after the epi- 
lation is performed an appropriate parasiticide should be employed. 
The calotte, made by spreading pitch-plaster upon leather or muslin, 
is a clumsy substitute for epilation in order to remove the hairs, but 
the sticks recommended by Bulkley may be employed, the formula for 
the preparation of which has already been given. In each case the 
epilation should remove a zone of sound hairs encircling the diseased 
patch, that the encroachments of the fungus may in every possible 
way be limited. It should not be forgotten, however, in the treatment 
of tinea tonsurans by both epilation and parasiticides that in chronic 
cases these methods in the hands of the most expert have failed for 



814 PARASITIC AFFECTIONS. 

consecutive months to relieve radically the disease ; that even the most 
inveterate cases in the course of time and as adult years are reached, 
are relieved spontaneously without permanent alopecia; and that no 
remedy or procedure is ever justifiable which is capable of either pro- 
ducing follicular atrophy or an effect worse than that wrought by the 
disease itself. Sabouraud 1 recommends a;-rays above other measures. 
Many others have followed his technique with good results. Al- 
though the method appears favorable it cannot be advised for gen- 
eral use owing to our inability to accurately measure the dosage even 
with all the modern appliances used for this purpose. 

Jackson 2 recommends an ointment containing a drachm (4.) of 
iodine crystals in an ounce (30.) of goose grease. This is rubbed into 
the scalp twice a day until swelling is produced. An alopecia follows 
but the hair returns. Levan 3 applies oil of turpentine on linen twice 
a day for a week, or until inflammation occurs. Exfoliation follows, 
the subsequent treatment being the application of a simple ointment. 
Hodara 4 applies daily, after shaving the hair, from 5 to 10 per cent, 
of chrysarobin in equal parts of glycerin and chloroform. On the 
production of erythema and oedema the treatment is suspended until 
the irritation has subsided, and then is renewed. Four or five months 
are necessary for a cure. Sabouraud 5 prescribes the following 
method : The scalp is shaved and the hair epilated from the diseased 
area and from a zone 4 or 5 mm. wide surrounding it. Every sec- 
ond evening the entire scalp is rubbed thoroughly with 60 per cent, 
alcohol containing 25 per cent, of pure iodine ; beginning areas of 
the disease not visible to the unaided eye are stained by the iodine 
and can be recognized easily. On alternate evenings an ointment 
containing pyrogallic acid, 15 grains (1.) ; oil of cade, 1 drachm (4.) ; 
and vaseline, 5 drachms (20.), is applied. The scalp is washed each 
morning with soap and hot water. If this treatment fails to produce 
a follicular inflammation, croton oil is added to the ointment. 

Coster's paste is popular among English practitioners, including 
Stowers, Fox, Liveing, and others. It contains 2 drachms (8.) of 
iodine in crystals, dissolved in one ounce (30.) of oil of tar; and is 
painted over the part at intervals of a few days. It is most useful in 
circumscribed patches of the disease. Among other remedies em- 
ployed, some of which have been described in connection with ring- 
worm of the body, may be named mercuric chloride, ammonio-chlor- 
ide, red oxide, oleate, and ointment of mercuric nitrate ; epispastics ; 
pure carbolic acid and carbolated glycerin ; sulphur, chloroform, ether, 
tar in ointment, and Wilkinson salve. 

To be effectual the treatment pursued must be persistent and thor- 
ough, and always be accompanied by frequent washings and soapings 
of the affected part. 

1 B. J. D., 1906, xviii., pp. 199, 214. A complete discussion of the subject with 
interesting details as to technique, apparatus, and results are given. 
2 N. Y. Med. Eecord. 1902, bri., p. 164. 

3 Jour. Mai. cutan., 1901, xiii., p. 241. 

4 Monatshef te, 1903, xxxvii., p. 118. 

6 La Pratique Dermatologique, iv., p. 508. 



TINEA TBICHOPHYTINA. 815 

The induction of suppuration in the hair-follicles (or a species of 
artificial kerion), by the aid of electrolysis and croton-oil liniment, 
has been praised by Alder Smith and Wyndham Cottle, of London, 
and later, in a modified form, by Magee Finny, of Dublin. By the 
process of Finny, 100 parts of the oil are mixed with 50 each of cocoa- 
butter and white wax. Sticks are made of this compound which can 
thoroughly be rubbed into the part affected. By both methods it is 
claimed that no pain is produced, nor is permanent alopecia the 
result. A solution of salicylic acid is applied after each treatment, 
and a subsequent poultice may also be needed. In these cases the 
parasite is destroyed presumably by the suppuration excited. As in 
the case of ringworm of the body, tinea tonsurans is not remediable 
by internal treatment. Such internal medication, however, may be 
indicated by the systemic condition of young patients, and should be 
in each instance such as that condition suggests. 

The treatment of kerion is either by the milder parasiticides or 
by the methods proper for the relief of ordinary phlegmonous inflam- 
mation of the scalp, according to the stage of the kerion. The pus- 
cocci present in some of these cases require boric-acid lotions and 
bichloride washes. 

The treatment of tinea sycosis is conducted generally as in tinea 
tonsurans. It is customary to begin by anointing the affected surface 
with an oily or fatty substance, and to follow this with a shampoo of 
soap and warm water for the removal of crusts, after which shaving 
and epilation are practised on alternate days; and parasiticides em- 
ployed locally. For softening the crusts the spray of an atomizer 
may be used. 

Epilation of the male beard is often essential for removal of the 
disease, but the results of the treatment suggested below in the end 
may be satisfactory. 

The patient for two successive days keeps the affected part macer- 
ated with almond- or olive-oil. On the evening of the third day the 
shampoo with soap is employed, and the skin is washed free from 
crusts and scales. The part is then cleanly shaved. This operation 
is at first painful, but gradually becomes less distressing. After shav- 
ing, the affected surface is bathed for ten minutes with borated water 
as hot as can be tolerated, by which means the inflammatory condition 
of the perifollicular tissues is, in a. brief time, considerably reduced. 
While the bathing is in progress all subepidermic pustules or points 
where a mucoid fluid is coming to the surface are opened with a fine 
aseptic needle. A solution of sodium hyposulphite is then sponged 
freely over the affected surface for several minutes and allowed to 
dry; this solution may contain 1 drachm (4.) to the ounce (30.), or 
even more. After a thorough and final washing with hot water the 
tender skin is carefully dried and gently smeared with a sulphur oint- 
ment containing 1 to 2 drachms of sulphur (4.-8.) to the ounce (30.) 
of vaselin, often with the addition of from \ to -i- (0.016-0.033) grain 
of mercuric sulphide. The patient then retires to bed. In the morn- 



816 PARASITIC AFFECTIONS. 

ing the unguent is washed off with soap and water, the sodium-solu- 
tion is reapplied, and a borated or a salicylated powder is thoroughly 
dusted and kept over the part during the day. In the evening the 
shaving may be repeated or not, according to the vigor with which the 
beard is reproduced, but on the second day shaving is imperative. 
As soon as the pustulation ceases and the tubercles have manifestly di- 
minished in size the ointment at night is superseded by the use, at that 
time also, of the dusting-powder. Whether the shaving is practiced 
nightly or on alternate nights, ablution with very hot water and with 
solution of sodium hyposulphite is continued nightly until the in- 
flammation excited by the fungus is practically limited to the follicles 
that are invaded. The dusting-powder is to be thoroughly and con- 
stantly employed after the ointment is discontinued. In many cases 
good results may be obtained by following the above technique, sub- 
stituting a 1 to 2000 solution of mercuric chloride for the boric acid 
bath and sodium hyposulphite solution, after which an ointment is 
applied containing ^ to 1 drachm (2.-4.) of hydrargyrum ammonia- 
turn to the ounce (30.) of adipis in place of the sulphur ointment. 
With care and patience these measures may save many patients the 
annoyance of epilation ; and they should be continued for several 
weeks after apparent relief of the disease. 

The treatment may be varied to suit the needs of individual cases. 
Kaposi highly recommends, for example, 1 per cent, solutions of 
corrosive sublimate locally; and the other parasiticides considered 
heretofore in connection with the treatment of ringworm may serve 
also a good purpose. In some cases an ointment of thymol may be 
used with manifest advantage ; in others, a substitute may be found in 
Morris's solution of the same in chloroform and oil (the formula for 
this has already been given). In still other cases spirit of green soap 
with sulphur, finely powdered sulphur, boric, acetic, and carbolic 
acids, or other topical applications of recognized value may be em- 
ployed. 

When resort is had to epilation, and this is essential in all severe 
cases, the hairs should be thoroughly removed from their follicles 
over every lumpy nodule, and even over every suspicious patch cov- 
ered with scales. A zone should be cleared about each such papule. 
The results are prompt and in the highest degree satisfactory. 

Prognosis. — Tinea circinata is often self-limited, and is generally 
under the simplest treatment satisfactorily relieved. Eczema margi- 
natum, especially in the crural region, may be obstinate, because it is 
an eczema as well as a parasitic disease, and, therefore, subject to the 
relapsed and chronic phases of the first-named disorder. Other in- 
tractable forms of the malady do, however, occasionally occur in 
adults, usually in tropical climates and tropical temperatures. 

The prognosis in every judiciously treated case of tinea tonsurans 
is favorable, since all patients ultimately recover from the disease 
per se. Under the best treatment many cases prove extraordinarily 
tedious, month after month passing without marked improvement. 



TINEA TBICHOPHYTINA. 817 

The disease, however, in a large proportion of cases among children 
surrounded by proper hygienic conditions, especially as regards clean- 
liness, is readily relieved. 

Tinea sycosis is always remedied sooner or later, though it is at 
times tedious in its progress and characterized by relapses. 

Precautions to be Observed in the General Management of Tinea 
Favosa and Tinea Trichophytina. 1 — The physician consulted in the 
case of a patient affected with either of the diseases thus far consid- 
ered as resulting from the presence of a vegetable parasite should bear 
in mind that they are the most contagious of their class. He may 
not only himself suffer from the disease which he is attempting to 
relieve in another, but may also convey it to others, or be consulted 
by others of his patient's family actually infected during the course of 
the treatment pursued. 

Generally, it may be said that the hands of the physician should 
carefully be washed after each manipulation of the part, and prefer- 
ably with a weak disinfecting solution. In the case of children the 
lining of all caps, hoods, and other coverings of the head should be 
removed and destroyed by burning ; and fresh linings made of tissue- 
paper renewed daily ; while paper-caps of the same or of similar mate- 
rial should be worn when indoors. Brushes, combs, towels, and arti- 
cles of clothing should never be used in common by two or more in- 
dividuals. When practicable, infected individuals should occupy sep- 
arate beds; and the bed-covering, clothing, toilet-apparatus, and 
dressing or other materials which have been in contact with a diseased 
surface should be immersed in boiling water before they are again em- 
ployed for any use in common. Thin recommends covering every dis- 
eased patch, after the treatment appropriate to itself, with an adhesive 
and impermeable dressing, for the sake, not of the patient, but of 
those with whom the latter may be brought in contact ; and the sug- 
gestion is both wise and practicable. A man infected with ringworm 
of the beard in a barbershop which he has visited but once, will often, 
when directed by his physician to shave, resort to some other estab- 
lishment, where he is well known, and where he has more confidence 
in the cleanliness of the operators. In this way he often thought- 
lessly spreads the disease of which he is the victim. It is well to send 
patients who cannot shave themselves to a particular barber, who, be- 
ing instructed in the manner of shaving so as to insure immunity, 
generally fails to spread the disease in any case. 

The physician should, in this connection, for medico-legal reasons 
be upon his guard against hastily deciding both as to the nature 
of the disease of his patient and the source from which it was de- 
rived. Of the first, he can become certain by his microscopical inves- 
tigations ; of the second, he can only be sure by obtaining possession 
of facts far beyond the reach of the average practitioner. A medical 
gentleman once sent for examination some hairs from the beard of 

1 Cf. Corlett, J. C. D., 1900, xviii., pp. 315 and 360. 
52 



818 PAEASITIC AFFECTIONS. 

a male patient affected with tinea sycosis. Before receiving a report 
confirming the diagnosis this physician was sued by the barber in 
whose establishment the disease had been probably acquired, on the 
ground of libel. 

TINEA VERSICOLOR. 

(Pityriasis Versicolor, Dermatomycosis Furfuracea, Mycosis 
Microsporia, Chloasma. Ger., Kleinenflechte.) 

Symptoms. — The eruption in this disorder occurs in the form of 
few or of many, irregular, roundish, circumscribed or reticulated 
macules, pinhead- to small-coin-sized, rarely occupying an area the 
size of the palm or larger. In color it varies from the most delicate 
buff or fawn shade to a reddish, deep-brown, and even blackish hue. 
The surface of each lesion, when closely inspected, is usually seen 
to be covered with furfuraceous scales. If the scales are not visible 
slight erasion with the finger-nail or the curette will demonstrate the 
fact that the superficial layers of the stratum corneum are, in the site 
of each lesion, readily separable from the tissues beneath. The erup- 
tion is most common upon the anterior surface of the thorax ; but it is 
displayed also upon the neck, the dorsum, the abdomen, and the other 
regions of the trunk, and the flexor aspects of the upper extremities 
(the hands only excepted). It rarely is seen upon the lower extremi- 
ties ; still more rarely on the face ; and on the hands and feet. 1 The 
eruption is either unproductive of sensation or is accompanied by a 
mild pruritus. Patients usually declare that after profuse sweating, 
bathing in warm water, or brisk friction of the surface minute epi- 
dermal rolls separate from the affected area. The disease may linger 
for years upon the surface of the body. It has a special tendency 
in susceptible individuals to recur after removal. 

The eruption is occasionally encountered in extreme development. 
In a young married woman who had been the subject of the disease 
for many years the entire trunk, the axillse, the groins, the upper por- 
tion of the thighs, the neck to the level of the high collar worn, and 
the upper extremities to the wrists, were encased in a uniform sheet 
or cuirass of chocolate-tinted epidermis in a condition of exfoliation 
in finger-nail-sized lamellated flakes. Even in these extreme cases 
the tendency of the disease to avoid surfaces exposed to the light is 
distinctly manifested. Unna 2 describes an anomalous feature of the 
disease, in which the maculations occur in annular form with a clear- 
ing centre. Rarely, also, a very few irregularly distributed macules 
may be seen as the sole evidences of the existence of the parasite. 
Thus, a patient may exhibit a small-coin-sized patch on the surface of 
the chest, another on the shoulder, and possibly a third over the del- 
toid region of one arm. These are generally cases partially relieved 
of a more diffuse eruption. More commonly the slightest manifesta- 

1 E. O. Smith, N. Y. Med. Jour., 1896, lxiv., p. 583, reports a case in which the 
disease was limited to both soles; and Gottheil, N. Y. Med. Rec, 1899, lvi., p. 
15, a case in which the left palm was involved. 

2 Vierteljahr., 1880, xii., p. 165. 



TINEA VERSICOLOR. 



819 



tion of the malady is an irregular, vertically arranged, somewhat nar- 
row band of lesions immediately over the sternum, and visible be- 
neath the hairs of that region in the adult male, or upon the inter- 
mammary sulcus of women. The face, hands, palms, soles, hairs, 
hair-follicles, and nails are usually exempt. 

Etiology. — The disease is produced by a vegetable mould, discov- 
ered in 1846 by Eichstedt, to which Kobin gave the name Microsporon 



Fig. 165. 




Copyright 1900 G. H. Fox. 
Chromophytosis guttata. 



(From Dr. G. H. Fox's Atlas of Skin Diseases.) 



furfur. In capabilities for contagion it is far inferior to the vege- 
table parasites already described, and it illustrates well a point to 
which attention already has been directed, viz., that these fungi 
nourish only in soils suitable for their germination and fructification. 



820 



PARASITIC AFFECTIONS. 



Members of one family are said to communicate the disease occasion- 
ally, the one to the other; and Lancereaux 1 reports that in this way 
he accidentally infected himself from scales collected for examination 
from a patient in hospital, and afterward unwittingly transmitted the 
affection to his wife. The disease occurs in both sexes, rarely before 
puberty and after middle life, and in persons of every social condi- 
tion, irrespective of personal cleanliness. It is exceedingly common, 
more so, indeed, than statistics are capable of demonstrating inasmuch 
as hundreds who are annually annoyed by it never seek professional 
advice. In physical examinations made with a view to the enlist- 
ment of men for military service, as also of government pensioners, 
the disease is often recognized upon the persons of those who pay no 
attention to its presence. Being concealed by the clothing and unpro- 
ductive of much discomfort, many subjects of tinea versicolor endure 
its presence with complacency. 

By some it has been supposed that the fungus selects the chest of 
the phthisical as its habitat, a supposition doubtless based upon the 
fact that tuberculous men and women, more than all others, expose 
the chest to the view of medical men in order to permit of its auscul- 
tation and percussion. 

Pathology. — The Microsporon furfur (Fig. 166) is readily recog- 
nized with the aid of the microscope, as it exists in luxurious profu- 




Microsporon furfur. (After Kaposi.) 



sion upon every affected surface. The scales may be scraped from the 
skin, placed on a slide moistened with a 1 to 10 per cent, solution of 
1 Traite d'Anatomie pathol., xi., p. 265. Paris, 1875. 



TINEA VERSICOLOR. 821 

potassium hydrate and at once be examined, when innumerable clus- 
tered spores and short threads become visible ; the former highly re- 
fractive and resembling in their circular and oval contours droplets of 
oil. Their aggregation in clusters is distinctive of this among the 
other forms of cryptogamic vegetation. They measure 0.0023 to 
0.0084 mm., while the hyphse vary in diameter from 0.0015 to 0.0038 
mm. (Duhring). Among the latter, sporophores are distinguishable, 
with contained conidia and terminal elements emerging at one ex- 
tremity or the other of the spore-case. Both elements are stained 
more readily by eosin and methyl-violet than those of the trichophy- 
ton or of favus. By the use of special media, Matzenauer 1 and Gras- 
tou and Nicolau 2 have succeeded in cultivating the fungus. 

One of the strongest arguments against the claim for the identity 
of all the vegetable parasites is furnished by the history of this inter- 
esting mould. It never by any possibility invades the hairs or the 
hair-follicles, though it may be seen nourishing at the orifice of a fol- 
licular duct, and even beneath a vigorous pilary growth upon the chest 
of a male subject. It avoids light and air; and singularly refuses to 
encroach even upon certain covered portions of the body, preferring, 
in its extreme development, to linger unobtrusively at the neck near 
the verge of the collar. 

Diagnosis. — In this disease, as in all parasitic affections of vege- 
table origin, the microscope may be required to decide the diagnosis 
in any case in which doubt arises. In its simpler manifestations the 
recognition of the affection is readily assured. The location of the 
eruption, its irregular reticulations, its characteristic yellowish or 
fawn-tinted shades of color due to the nature of the fungus, and the 
exfoliation of the epidermis which it excites by its superficial pene- 
tration of the outer layer of the stratum corneum, producing thus a 
mealy, branny, flaky, or roll-like exuvium, are all significant. None 
of the chloasmata due to pigment-changes in the skin, however much 
they may resemble tinea versicolor in color, share with it this pecu- 
liarity of desquamation. Chloasma may involve, moreover, the face ; 
tinea versicolor almost never. Vitiligo occurs upon the scalp ; tinea 
versicolor very rarely. The macular syphiloderm may be mistaken 
for the disease under consideration, but, when developed to such an 
extent as to rival tinea versicolor in its diffuseness, the syphiloderm 
will creep out over the face, the hands, and the feet, and will be ac- 
companied by adenopathy, alopecia, mucous patches, palatine hyperse- 
mia, or will furnish evidence of a polymorphic tendency. Often, in- 
deed, with such an eruption, the survival of the initial sclerosis will 
at once betray the nature of the disease. These are important consid- 
erations, since in the mere matter of subjective sensation, color, shape, 
and size of lesion there mav be marked resemblance between the two. 
Patients exhibiting the lesions of tinea versicolor may suffer from 
syphilis ; and many having the former disease, in consequence of a sus- 

1 Archiv, 1901, Ivi., p. 163. 

2 Bull, de la Soc. fran§ de Dermat., 1902. 



822 FARAS1TIC AFFECTIONS. 

picious exposure believe they are infected with lues, and yet indeed 
are not. These incidents serve to illustrate the importance of making 
an accurate diagnosis in every case of cutaneous disease. 

The most common error committed in this connection, however, is 
based upon the fancied resemblance in color between the patches of 
tinea versicolor and either the liver itself or the color-changes which 
disease of that viscus is capable of producing in the skin. The exist- 
ence of " liver-colored " spots in the skin is, hence, erroneously attrib- 
uted to hepatic disease. Few patients consult physicians for relief 
of this disorder who have not a belief in the internal origin of the 
disease. 

Treatment. — A single method of relieving tinea versicolor is 
recommended for the simple reason that it invariably is successful. 
It requires merely vigorous and intelligent cooperation on the part of 
the patient. A hot bath is taken, if possible, for three nights in suc- 
cession, and when the surface is well macerated in hot water the 
affected skin is scrubbed either with the cheap yellow soap of the 
shops, or with sapo viridis in substance or in tincture. When the 
disease is extensively developed this process is aided by friction with 
a flesh-brush or with a coarse towel. The skin is then washed clean 
with a surplus of hot water, and dried, after which the affected patch 
is first moistened with vinegar and water, or dilute acetic acid, and 
afterward well sponged with a solution of sodium hyposulphite, 1 
drachm (4.) to the ounce (30.) being usually sufficient. As a rule, 
the greater part of the eruption is removed with the third application. 
If there be recrudescence in isolated patches, as is often the case, or 
outlying areas which have withstood the parasiticide employed, they 
should subsequently be attacked with a solution of mercuric chloride, 
1 to 2 grains (0.066-0.133) to the ounce (30.). Other measures, 
however, are popular with physicians, and among them may be named 
the topical use of boric, carbolic, or sulphurous acid ; tincture of 
iodine; sulphur in bath, ointment, or lotion; calomel in ointment; 
the alkalies in bath or lotion; potassium sulnhide in bath; chrysa- 
robin, pyrogallol, tar, Wilkinson's salve, and the other parasiticides 
employed in the treatment of ringworm of the body. Leven 1 secures 
an exfoliation of the skin and a removal of the disease by embrocation 
of oil of turpentine four or five nights in succession. Whatever para- 
siticide be employed, after treatment the inner clothing should not 
be worn until it has been immersed in boiling water. 

The following formula is also recommended : 

]J Hydrarg. chlorid. corros., 
Saponis viridis. 
Spts. vin. rectif., 
01. lavandul.. 



Prognosis. — The disease can readily be relieved by simple treat- 
ment. Relapses often occur, and require to be radically treated. 

1 Monatshefte, 1901, sxxii., p. 197. 



3.1; 


1|33 


sy ; 


60| 


£v; 


120 


Sj; 


4| M. 




[Anderson.] 



ERYTHRASMA. 823 

Untreated, the disease may continue for years without the slightest im- 
pairment of the general health. It is probable that when untreated 
the parasite undergoes spontaneous exfoliation in advanced years, a 
period when presumably the fungus fails to find in the epidermis the 
nutriment upon which it thrives. 

ERYTHRASMA.i 

(Gr., epvdp6c, red.) 

Burckhardt first described this disorder in 1869, but it received 
its name in 1862 from von Barensprung. It has since been studied 
and described by Balzer, Biehl, Koebner, Pick, and others. 

Symptoms. — The disease first appears in punctiform to palm- 
sized, roundish,, definitely circumscribed maculations, presenting a 
sharp contrast in color with that of the adjacent integument. This 
hue varies somewhat according to the location of the patches. The 
younger lesions may exhibit a vivid redness over the entire macules 
or over their borders only. The older lesions exhibit a yellowish or a 
brownish tinge. These colors are compounds of ordinary erythema- 
tous redness and yellowish or brownish discoloration of the horny 
layer of the epidermis. 

The macules are circular or rosette-shaped, or they display very 
irregular outlines. They are not raised to any extent above the gen- 

PlG. 167. 




Microsporon minutissimum, from patches of erythrasma. 

eral level of the skin, though the finger passed over the surface can 
recognize a slight elevation of the border, due to hyperemia, and sub- 
sequent moderate, flour-like furfuraceous desquamation most conspic- 

1 Cf. Payne, Some Eare Diseases of the Skin, London, 1899 (review of litera- 
ture) ; Balzer, La Pratique Dermatologique, ii., p. 540 (bibliography). 



824 PARASITIC AFFECTIONS. 

uous also at the periphery. Vesiculation and papulation do not occur. 
The colors recognized in different patches may be light reddish-brown, 
pale reddish-yellow, and light or dark orange. 

The eruption is most commonly encountered where apposed sur- 
faces of the skin come in contact, as in the axillae, the groins, the cleft 
of the nates, and the regions where the scrotum touches the thigh ; it 
occurs, however, in typical expression on both sides of the chest. The 
eruption spreads slowly and in serpiginous outline until the affected 
surfaces are completely invaded. It is much more chronic in its 
course than the other dermato-mycoses, lasting for months and years 
without apparent change. 

Etiology.- — Erythrasma is produced by the growth, in the super- 
ficial layers of the epidermis, of the fungus described below. Men 
are much more often affected than women ; children not at all. The 
youngest patient whose case is recorded was sixteen years old ; the 
oldest fifty-five. 

Pathology. — The fungus termed Microsporon minutissimum 
(Fig. 167), to which the disease is attributed, is chiefly remarkable 
for the extraordinary delicacy and fineness of its threads and its very 
minute spores. The threads are either simple cylindrical bodies of 
variable size, or they may exhibit partition-septa; they may divide 
dichotomously, and may terminate in hooked or knobbed expansions. 
They are inextricably interwoven when occurring in large masses. 
The largest transverse diameter is 0.6 n; in length the mycelium pre- 
sents the greatest variation. Bacteria and heaps of zooglcea are 
visible among the scales. The granules are piled into irregular heaps 
according to Burckhardt, and they give a dusty appearance to the epi- 
dermal cells on which they lie ; often the outline of these granules 
is indistinct. According to the same observer, the breadth of the 
hyphse is /1200 mm. ; and the length from M.5 to /4oo mm. 

Pasquale de Michele 1 discovered the leptothrix in cases of sup- 
posed ervthrasma; and this is but another of the proofs that in all 
diseases of this class, as in so-called " eczema marginatum," there are 
few instances in which a single mould-fungus develops on the body 
surface. The entire flora dermatologica of Unna may be effective in 
more cases than is commonly believed. 

Diagnosis. — From all ordinary chloasmata and pigment-macules 
the spots of erythrasma are distinguishable by the ease with which 
the superficially embrowned epidermal layers are removed by erasion. 
Tinea versicolor is distinguished from erythrasma with greater diffi- 
culty; but the latter occurs in different situations by preference, its 
patches are more vividly tinted, and the parasite, under the micro- 
scope, presents distinctive features. 

Treatment is that of tinea versicolor. 

Prognosis is favorable, subject to the disappointments arising 
from frequent relapses. 

1 Cf. Aimales, 1891, s. iii., ii., p. 776. 



PLATE XLVIII 




Blastomycosis. 

(From a photograph.) 



BLASTOMYCOSIS. 825 



BLASTOMYCOSIS.! 

(Blastomycetic Dermatitis, Saccharomycosis Hominis, Derma- 
titis Blastomycotica. Ger., Hefenmykose.) 

Cutaneous blastomycosis is a chronic, inflammatory, infectious 
disease, characterized by the appearance upon the skin of a small pap- 
ule or papulo-pustule, which becomes crusted and extends peripherally 
to form a sharply outlined, elevated, verrucous patch situated upon a 
pus-infiltrated base and presenting a characteristic, abruptly sloping 
border in which are seen minute, deeply seated abscesses. Blastomy- 
cetes are found in the sero-purulent contents of the abscesses, from 
which both budding and mycelial forms of organism have been ob- 
tained in pure culture. 

The invasion of the bodies of animals by blastomycetes had been 
studied before the disorder was recognized in the human family. In 
1894 Busse published an account of a fatal case of pyaemia, with 
subcutaneous abscesses and cutaneous manifestations, in which the 
pathogenic agent was a yeast. A few months earlier, Gilchrist had 
demonstrated before the American Dermatological Association micro- 
scopic sections containing budding organisms from a lesion which 
Duhring considered a scrofuloderm. Later communications from 
Busse and Buschke and from Gilchrist and Stokes have been followed 
by reports from a number of observers, including Curtis, Wells, Hess- 
ler, Anthony, Brayton, Stelwagon, Dyer, Shepherd, and ourselves. 
The records of nearly one hundred cases published or unpublished, 
in which the nature of the disease has been demonstrated satisfac- 

1 For a more detailed review of the clinical, histological, and bacteriological 
features of cutaneous blastomycosis, with 16 clinical and 25 histological and 
bacteriological illustrations, a brief summary of 13 of our own cases, and bibli- 
ography, see report, Jour. Amer. Med. Assoc, 1902, i., p. 1486. For a full con- 
sideration of experimental work, and animal inoculations with blastomycetes, see 
Buschke's complete monograph, Bibliotheca Medica, D. II. H. 10, 1902 (illus- 
trations and bibliography) ; and monograph : " De la Blastomycose humaine, ' ' 
by Harter, Nancy, 1909. For valuable contributions and full references to re- 
searches on blastomycetes, protozoa, cancer bodies, and cell inclusions, see the 
Second Annual Beport of the Cancer Committee to the Surgical Department of 
Harvard Medical School, Jour. Med. Besch., 1902, vii., No. 3. 

Becent eases: Gilchrist, a case in a negro, with illustrations, review, and bibli- 
ography, Brit. Med. Jour., 1902, ii., p. 1321. Sheldon, report of a case, Jour. Amer. 
Med. Assoc, 1902, ii., p. 1356. F. H. Montgomery, a case of cutaneous blastomyco- 
sis followed by systemic tuberculosis, J. C. D., 1903, xxi., p. 19. Ormsby and Miller, 
a systemic case with multiple cutaneous and subcutaneous lesions, a full report 
with illustrations. Sequeira, report of a case, B. J. D., 1903, xv., p. 121. Evans, 
" A Case of Cutaneous Blastomycosis from Accidental Inoculation," Jour. Amer. 
Med. Assoc, 1903, p. 1772. Fusey, two cases presented to the Chicago Derm. 
Soc, J. C. D., 1903, xxi., p. 223. Fischkin, report of a case, 111. Med. Jour., 1903, 
v., p. 472. Gilchrist, three cases, with four clinical illustrations, and abstract of 
McCarrison's report of a case which occurred in a native of Northern India. 
J. C. D., 1904, xxii., p. 107. Montgomery and Ormsby, Archives of Internal 
Medicine, August, 1908, " Systemic Blastomycosis — Its Etiologic, Fathologic. 
and Clinical Features as established by a Critical Survey and Summary of 
Twenty-two cases, seven previously unpublished; the Eelation of Blastomycosis 
to Coccidioidal Granuloma." In this review the authors give an abstract of 
twenty-two established and five probable cases of systemic blastomycosis. For 
a review of the entire subject the reader is referred to the original article. 



826 PARASITIC AFFECTIONS. 

torily, are now available. The following description is based chiefly 
on the clinical, pathological, and bacteriological study of a large num- 
ber of cases of both cutaneous and systemic blastomycosis. 

Symptoms. — The disorder in the skin begins as a papule or pap- 
ulopustule, which soon becomes covered with a crust. The lesion 
slowly enlarges peripherally in the form of an indolent, flat, wart-like 
or crusted papule. In the majority of all cases the lesions had existed 
a number of months and had attained a diameter of an inch or more 
before the patient applied for treatment. We have had the oppor- 
tunity once of watching a lesion grow from the initial small papule. 

In lesions that have attained the diameter of half an inch or more, 
the following characteristics are apparent : The patch is elevated from 
one-eighth to three-eighths of an inch above the surrounding skin; 
the surface is covered by irregular papilliform elevations, separated 
by clefts or fissures of varying depth, giving it a verrucous or cauli- 
flower appearance. In the younger and near the border of the older 
lesions, especially of those which have been kept clean, the papillary 
projections are fine and the surface is fairly firm, dry, and wart-like. 
Portions of larger areas, and especially of those which have been un- 
treated, are covered by more or less bulky and adherent crusts, on re- 
moval of which the papillary elevations are seen to be larger, lobu- 
lated, even subdivided, and bathed with a sero-purulent secretion. 
Some of these crust-covered projections are very vascular, a slight 
touch causing them to bleed. In exceptional instances the area under 
a crust may present the appearance of an ordinary unhealthy ulcer, 
with exuberant granulations. In older lesions, the papillomatous sur- 
face may be replaced in part with a thick, elevated, scar-like forma- 
tion, pinkish-white in color, irregular and often corded, but having a 
smooth, shining surface. The base of the active lesion is always soft 
and more or less infiltrated with sero-pus, which, on slight pressure, 
oozes between the papular elevations. 

The border of the area is one of the most characteristic features. 
It slopes more or less abruptly from the elevated roughened surface to 
the normal skin, from which it is sharply defined. It is smooth, of a 
dark red or purplish-red color, is from one-eighth to three-eighths of 
an inch wide, and on close inspection is seen to be beset with a large 
number of minute abscesses. Many of these abscesses are so small 
that they are not visible to the naked eye, but can be recognized with 
a lens magnifying from two to six diameters. Others vary in size 
up to that of a pinhead. Some are superficial, but many, especially 
the smaller ones, are deep-seated. When carefully punctured with a 
fine needle, these abscesses give exit to a small amount of thick, 
glairy mucus or muco-pus, the purulent character of the secretion in- 
creasing with the size of the pustule. From the smallest abscesses the 
amount of mucus expressed is sometimes so scanty that it can only be 
seen with the aid of a lens, yet it is from these minute abscesses that 
the organisms are best obtained in pure culture. Abscesses of the 
same sort occur also in other parts of the growth, and not infrequently 



PLATE XLIX 







SB 




. vv..«. '•- * »'*vi 


I 



Clinical Types of Cutaneous Blastomycosis. 



BLASTOMYCOSIS. 827 

on the thick, scar-like tissue described above, but in characteristic 
development they are best seen on the sloping border. The number of 
abscesses varies in different cases and in the same case at different 
times, depending somewhat upon the activity of the process. 

The cutaneous lesions found in the systemic cases only occasion- 
ally correspond to the above description. They are found chiefly in 
the form of irregular, ragged, rather superficial ulcers, having a soft 
base, a granulating floor, and a purulent or sanguineo-purulent dis- 
charge which often forms bulky crusts. These ulcers are usually 
preceded by subcutaneous abscesses which gradually or rapidly 
extend to the surface and rupture externally. These subcutaneous 
nodules and abscesses are characteristic of the systemic cases and 
often occur in successive crops. 1 

The course of the disease is irregular but essentially chronic. 
Usually months elapse before the original patch attains a diameter 
of an inch or more. It may remain indolent for months or even 
years, with irregular periods of activity and progress, but, as a 
rule extension of the area is slow and continuous. In about half the 
cases the original patch of the disease has been followed in the 
course of weeks or months by one or more new lesions in adjacent or 
other regions of the body. In some instances the clinical evidence 
of auto-infection has been very strong. The majority of the areas 
sooner or later attain the size of a silver dollar or of the palm, and 
some of them become much larger. As the disease ends at the periph- 
ery, healing frequently occurs in the central portion of the growth. 
In this manner large areas (in Anthony and Herzog's patient the 
greater portion of the thigh and leg) may be involved in various stages 
of the process. Healing sometimes occurs spontaneously. Whether 
spontaneously or as the result of treatment, the first indication of 
healing is found in the gradual flattening and disappearance of the 
papillary projections, partly by absorption, partly by desiccation and 
exfoliation. At the same time the amount of secretion from the un- 
derlying base diminishes, and the whole patch assumes more of an 
ordinary verrucous appearance. In many instances the papilliform 
surface is replaced temporarily by the hypertrophic scar-like tissue 
described above, which in turn gradually disappears and gives place 
to the characteristic cicatrix, which eventually becomes soft, supple, 
non-attached, pinkish-white, and, on the whole, very inconspicuous, 
though always sharply outlined from the surrounding skin. As a 
rule, the resulting deformity is very slight. In some instances where 
destructive agents or scraping operations have been employed, the 
disappearance of the characteristic lesion is followed by an ordinary 
indolent ulcer, which heals with a thickened and somewhat deforming 
scar. 

During the healing process, though the miliary abscesses decrease 
in number, careful search will reveal them even in scar-tissue that has 
become quite thin and soft. It is consequently not uncommon to see 
1 Archives of Internal Medicine, August, 1908. 



828 PARASITIC AFFECTIONS. 

areas that apparently have healed, become more or less covered again 
with active points or areas of disease. A single patch may thus 
present nearly all stages of the disorder, showing at the same time sev- 
eral of the following features : the advancing border ; new-forming 
lesions on old scars ; verrucous or cauliflower lesions in various stages 
of development or disappearance ; a base in places dry and firm and 
in others soft and infiltrated with muco-pus; a scar-tissue, in part 
thick and irregular and in part smooth, soft, supple, and non-atttached 
to the deeper tissues. 

The regions involved are usually those most accessible to local in- 
fection, the disease occurring with greatest frequency on the face, 
hands, wrists, or forearms ; but no portion of the body is exempt. 
The eyelids are a frequent seat of the disease, but the conjunctiva 
escapes, though ectropion resulting from destruction of the lid causes 
conjunctivitis and keratitis, due to exposure. Adenopathy has been 
noted in systemic cases only, though pus infection of lesions may be 
followed by a transitory involvement of adjacent glands. 

The subjective sensations of the disease vary greatly. As a rule 
pain is slight or absent except in areas which are acutely inflamed as 
a result of secondary infection. 

The majority of patients have been in good general health, though 
some have suffered from other systemic disorders, which evidently 
bore no definite relation to the blastomycosis. Of the entire number, 
one patient only died of generalized tuberculosis. In nineteen cases 
death occurred from systemic infection with blastomycetes, the or- 
ganisms being demonstrated at the autopsy in the viscera, and in three 
cases in the blood. One of the nineteen patients 1 remained in vig- 
orous health for seven years after the appearance of cutaneous lesions 
and then rapidly developed grave constitutional symptoms. 2 

Etiology. — A local infection with the fungus peculiar to each case 
is the sole recognized cause of the disease. In one instance a slight 
wound of the finger incurred at the autopsy of a case of systemic 
blastomycosis was followed in one week by the appearance at the site 
of the injury of a pustule which refused to heal and later developed 
into a typical cutaneous lesion in which budding organisms were dem- 
onstrated repeatedly. The infectious character of the disorder is 
demonstrated further by successful inoculation of animals. In sev- 
eral instances there has been a history of trauma preceding infection. 
What other conditions favor the origin and development of the process 
have not been determined. Why certain yeasts and mould fungi are 
pathogenic, while others are innocuous, how common in nature the 
pathogenic varieties are, and how they differ from the ordinary va- 
rieties, are unsolved problems. 

~No relation has been discovered between the disease and the sex, 
occupation, nativity, or habits of the individual affected. The fact 
that the majority of cases occur in men is due probably to their more 

1 Montgomery -Walker case. 

2 Archives of Internal Medicine, August, 1908. Discussion of clinical symp- 
toms exhibited in systemic cases. 



PLATE L 




*V$^#$8I 



> -- .y ■-.'-• 



7*' 



Vertical Section from a Typical Lesion. 

a, hyperplasia of rete; b, abscesses in epithelium; c, infiltration of cutis. 55. 





Budding Organism in Hanging Drop. X 1200. 

Tissue, x 1200. 

BLASTOMYCOSIS OF THE SKIN. 

(From a photomicrograph.) 



BLASTOMYCOSIS. 829 

frequent exposure to infection. About half the cases have occurred 
after the age of forty with the majority of the remainder between 
twenty and forty. Recently it has been observed in younger subj ects, 
the youngest 1 being 8 months old at the time the nature of the disease 
was established. ]STo definite relations between blastomycosis and 
other local or systemic disease has been demonstrated. The possi- 
bility of blastomycotic infection being secondary to lesions of other 
disorders or to trauma is admitted; it is equally possible for the 
lesions of blastomycosis to be infected secondarily with tuberculosis or 
other disease. 

Pathology.- — Histologically the lesions resemble those of verru- 
cous tuberculosis or of superficial epithelioma, yet differ from both. 
The surface on which are seen irregular masses of debris consisting of 
pus, blood- and epithelial cells, and various bacteria, is marked by 
irregular papilliform projections, between which are corresponding 
depressions. The horny layer may be destroyed or it may extend in 
thickened masses between distorted papilla?. 

The rete is everywhere the seat of excessive hyperplasia, produc- 
ing branching down-growths varying greatly in size and shape. 
Polymorphonuclear leucocytes are scattered throughout the epithe- 
lium, both between and within the cells, and occur often in small 
collections which are the beginning of miliary abscesses. These 
abscesses are characteristic of the process, and are found in all parts 
of the hyperplastic epithelium, in places breaking through to the 
surface. They contain leucocytes, nuclear fragments, detached 
epithelial cells, epithelial detritus, red blood-corpuscles, the organ- 
isms peculiar to the disease, and in many cases giant-cells. The 
epithelial cells surrounding the abscesses are flattened, but appear to 
take no active part in the process. The epithelium is separated from 
the corium in most places by a distinct layer of columnar cells, in which 
mitoses are seen occasionally. The rete-cells in general are large and 
appear swollen, the prickles being very conspicuous and the intercel- 
ular spaces increased. Premature cornification, more or less com- 
plete, occurs in scattered individual cells, in groups of cells, and oc- 
casionally in isolated epithelial whorls. Single giant-cells, sur- 
rounded by a few leucocytes, are sometimes seen in the epithelium at 
some distance from the corium. 

The corium is the seat of subacute, chronic, and occasionally of 
acute inflammatory changes. Miliary abscesses occur, especially in 
acute lesions. The infiltration consists chiefly of leucocytes, endothe- 
lial cells, and plasma-cells, and is sometimes very dense. The num- 
ber of mast-cells and giant-cells varies in different cases. Tubercle- 
like nodules are found in some instances. In several cases sections 
showed numerous hyalin bodies which varied greatly in size, and 
occurred chiefly in plasma-, giant-, and new connective-tissue cells. 

The appendages of, the skin apparently play but a passive part in 
the process. 

1 Kessler, J. B., Jour. Amer. Med. Assoc, 1907, slix., pp. 550-552. 



830 PAEASITIC AFFECTIONS. 

The blastomycetes are found in miliary abscesses, between the 
epithelial cells and in the coriuin, and are always surrounded by more 
or less evidence of inflammation. They are rarely found within the 
cells. The giant-cells, however, usually contain one or more of the 
parasites. The number present in the tissue varies greatly. In some 
cases a dozen or more can be seen in a single field of the microscope, 
while in others they are found with difficulty. They occur usually in 
pairs of unequal size, but also singly and in groups. They are readily 
seen in sections stained with hematoxylin and eosin or other common 
stains, but methylene-blue is best for showing the different parts of 
the organism. The fungus is easily demonstrated by placing fresh 
or hardened sections, or pus, in a strong solution of potassium hy- 
droxide, or in equal parts of liquor potassre and glycerin ; the organ- 
isms then appear as doubly contoured, highly refractive bodies. 

When well stained, the parasite is seen to be a round, oval, or 
slightly irregular body, having a well-defined, double-contoured, homo- 
geneous capsule, and a finely or coarsely granular protoplasm, which 
is separated from the capsule by a clear space of varying width. The 
capsule resists the prolonged action of strong alkalies and acids. The 
protoplasm often contains a clear vacuole, which varies greatly in size 
in different bodies. Mature organisms have a diameter of from 7 
to 20 ^., though smaller and larger forms are seen occasionally. 

Budding forms are seen in all stages of development ; the capsules 
and clear space are pushed out apparently by the protoplasm to form 
oval buds, which grow to about one-half the size of the mother-cell 
before sejDarating from the latter. Organisms in pairs of unequal 
size are more common than budding forms. 

Mycelium has not been demonstrated in tissue or in the contents 
of the abscesses. In two cases organisms in the tissues were filled 
with small globular bodies which reacted to stains like spores but no 
further development of these bodies could be seen. 1 

In a systemic case, Ormsby excised a small-bean-sized subcuta- 
neous node, in which the epidermis was normal and the corium but 
slightly involved, the process being manifested chiefly in the subcuta- 
neous tissue. The zones of infiltration were for the most part fairly 
well defined about dilated blood-vessels. The infiltration consisted of 
large numbers of the organism, also leucocytes, erythrocytes, connec- 
tive-tissue, plasma-, mast-, and giant-cells in varying numbers. In 
places there was a suggestion of tubercle formation, in that the organ- 
isms, leucocytes, and red-blood cells were found chiefly in the centre 
of the node and surrounded by giant-, connective-tissue, and plasma- 
cells. In this and other systemic cases the organisms were very num- 
erous and larger than those found in most of the cutaneous cases. 

The organism is obtained easily in pure culture from the minute 
deep-seated abscesses in the borders of the cutaneous lesions. Cul- 
tures taken from the larger abscesses and from teased tissue are con- 

1 In a single case we found in the larger abscesses a few pod-like bodies, and 
fragments of a thick mycelium containing what appeared to be spores. 



BLASTOMYCOSIS. 83 1 

taminated often with pus-cocci or other bacteria. The blastomycetes 
have been obtained repeatedly, however, in pure culture from pus- 
abscesses of considerable size, showing that the organisms are in them- 
selves pus-producing. In cultural features the organisms from dif- 
ferent cases have varied considerably, and it is possible that they will 
have to be classed in distinct botanic groups. On the other hand, 
individual organisms have been shown to vary greatly with the media 
employed and with other circumstances of culture, and the different 
types seen may be various stages of development of a single variety of 
fungus. 1 The organisms grow rapidly on most ordinary media, and 
though by varying the media and other circumstances of growth a 
given organism can be made to assume a variety of appearances, in 
most instances the type is that of a mould fungus, showing on agar or 
glucose agar a white, fluffy growth with aerial hyphse, and on glycerin 
agar a pasty growth with numerous folds and depressions. 

• Under the microscope, cultures show budding organisms and myce- 
lium, that may be fine, homogeneous, and branching, or coarser, more 
or less segmented, with or without lateral conidia. The mycelium 
may contain few or many highly refractive bodies, varying in size, 
which probably are spores. Mingled with the mycelium of older cul- 
tures are round, oval or irregular, double-contoured bodies, varying 
greatly in size and more or less filled with highly refractive, globular 
bodies. These globular bodies, like those seen in the coarser myce- 
lium, behave in every way toward reagents like spores, but in no case 
have they been observed to develop into mature organisms. 2 Young 
colonies and cultures on glucose agar are made up of fine mycelium, 
with or without the presence of budding organisms. Older cultures 
and those on glycerine agar show much coarser mycelium and a pre- 
ponderance of the circular spore-containing bodies. A bit of old cul- 
ture made up entirely of these round bodies, placed in a hanging drop 
of bouillon, develops in two or three days an abundant fine mycelium, 
in which the spore-like bodies are disseminated. 

Though in tissues and in the abscesses the organism develops by 
budding only, fresh cultures from the abscesses show fine mycelium 
more frequently than budding forms. Animals inoculated with cul- 
tures composed of mycelium have developed abscesses from which 
budding forms only were obtained. 

Inoculation-tests have been largely unsuccessful, but in several in- 
stances subcutaneous injection of pure cultures of the blastomycetes 
has resulted in the production of a local abscess, or of an inflammatory 
granulation-tissue, from which the fungus could be recovered. Intra- 
peritoneal injections were unusually successful with the organism 
from a systemic case reported by Montgomery. 3 By inoculating the 
skin of animals with pure cultures of blastomycetes, Buschke suc- 
ceeded in producing tumors which resembled closely the lesions of 

1 Hamburger, Jour. Infect. Dis., 1907, iv., p. 201. 

2 Under certain conditions blastomycetes may develop by sporulation. 

3 J. C. D., 1907, xxv., p. 393. 



832 PARASITIC AFFECTIONS. 

cutaneous blastomycosis in man. The organisms in several cases have 
been inoculated in animals with the production of tubercular-like no- 
dules, or other inflammatory areas, in the lungs, kidneys, and other 
organs, from which the fungus has been recovered and cultivated. 

Diagnosis. — Though many of the cutaneous lesions of blastomy- 
cosis resemble verrucous tuberculosis so closely that a definite diag- 
nosis can be established only after a microscopic examination of the 
tissue or of the contents of minute abscesses, lesions showing the typ- 
ical border set with abscesses described above are so characteristic and 
are present so frequently that a positive clinical diagnosis is possible 
in most cases. 

The readiest means of confirming the diagnosis is to place the 
contents of one or more of the abscesses, or a bit of teased tissue, be- 
tween a slide and cover-glass with a drop of a 20 or 30 per cent, solu- 
tion of potassium hydrate. If distinct budding organisms are found, 
which resist the action of the alkali after the tissue and pus-cells 
have largely disintegrated (a change requiring from ten minutes to 
one hour), the diagnosis is practically established, but should be veri- 
fied further by obtaining cultures of the organism and by histological 
examination of the tissue. 

Other disorders to be excluded by a consideration of their char- 
acteristic features are lupus vulgaris and other tuberculoses of the 
skin, the rare vegetating forms of syphilis, and protozoan infection, 
which, it is now believed, may be a variant of blastomycosis. 

Treatment. — Complete excision of the diseased areas has been 
practised successfully in several cases, no recurrence having been 
reported. Curetting, employed in a number of instances, has not 
prevented a return of the disease. 

Large doses of potassium iodide, first employed by Bevan with 
one of our patients, arrests the progress of the disease and produces 
a marked improvement in the cutaneous lesions. From two to five 
hundred grains a day have been required in some patients before any 
effect on the morbid growth was produced. In three of our cases and 
in several reported by others the disease disappeared under this treat- 
ment. In the majority of patients, however, treated with large doses 
of potassium iodide, healing takes place rapidly over the greater por- 
tion of the area involved, but small patches remain, usually of the 
verrucous border, for indefinite periods ; and on the discontinuance 
of the potassium iodide the disease reappears with as great activity 
as before. In three of our patients who improved rapidly under the 
treatment up to a given point, the few remaining verrucous areas 
and abscesses disappeared after a few exposures to the a:-rays. Pusey, 
Fischkin, and others have had good results from the combined use of 
potassium iodide and the x-vajs. 

More recently Bevan 1 recommended copper sulphate in one quar- 
ter grain (.016) doses internally with a one per cent, solution of the 
same as a local wet dressing. 

1 Jour. Am. Med. Assoc, 1905. Nov. 11. 



SPOBOTBICHOSIS. 833 

For most lesions, cleansing and antiseptic lotions or dry dressings 
can be used with advantage. 

Prognosis. — Complete excision when practised has terminated 
the disease. Under the iodine therapy, the condition improves so de- 
cidedly that with the aid of the rr-rays, or other local treatment, the 
disease should be eradicated completely. Recurrences, however, are 
common, even after the last clinical evidence except scars has been 
removed. 

The prognosis in systemic cases is grave as in 19 out of 22 patients 
the disease proved fatal. 

PROTOZOIC AND COCCIDIOIDAL INFECTIONS. 

Protozoic and coccidioidal 1 infections of the skin have been re- 
ported by Wernicke, Rixford and Gilchrist, 2 Posadas, D. W. Mont- 
gomery, 3 and Ophiils and Moffit, in which the cutaneous manifesta- 
tions both clinically and histologically, resemble very closely those of 
cutaneous blastomycosis. In the general symptoms, in the forma- 
tion of subcutaneous abscesses, in the fatal termination, and in the 
larger size and greater number of organisms in the lesions, these cases 
correspond closely with those of systemic blastomycosis, with which 
they undoubtedly are allied closely if not identical. In cases of 
coccidioidal infection the organism develops by endogenous spore- 
formation and never by budding; while in blastomycosis the only 
method of development of the organism in tissue is by budding. 
Though in at least two cases of the latter disease the organisms have 
contained what undoubtedly were endogenous spores, the develop- 
ment of these spores into mature bodies could not be demonstrated. 
The cultures obtained from cases of coccidioidal infection differ 
slightly from those obtained repeatedly in blastomycosis. It is pos- 
sible that the difference between the organisms in blastomycosis and 
in coccidioidal disease may be due to the influence of climate, all 
reported cases of coccidioidal disease having originated in warm 
countries. 

SPOROTRICHOSIS.* 

In 1898 Schenck 5 reported the findings in a patient who developed 
multiple subcutaneous abscesses along the course of the lymphatics up 
the arm starting from a wound of the finger. The abscesses when 
opened contained a gelatinous or aqueous fluid and from this a sporo- 
thrix was isolated. In 1900 Hektoen 6 and Perkins reported a similar 

x For comparison between coccidioidal granuloma and systemic blastomy- 
cosis see Archives of Internal Med., August, 1908. 

2 Johns Hopkins Hospital Eeports, i., 1896 (a full report of two eases and of 
the organisms, with illustrations). 

3 B. J. D., 1900, xii., p. 343 (bibliography), and J. C. D., 1903, xxi., p. 5 (a 
new case). 

4 Mewborn, A. D., J. C. D., 1908, xxvi., pp. 140-143; gives an excellent review 
of recorded cases with full bibliography. 

5 Johns Hopkins Hospital Bull., 1898, p. 286. 

6 Journ. Exper. Med., 1900, p. 77. 
53 



834 PARASITIC AFFECTIONS. 

case as to clinical symptoms and bacteriological findings. In 1899 
Brayton 1 made a clinical report of an apparently similar case. In 
1903 De Beurmann 2 and Ramond described a case from which the 
same parasite was cultivated. There are now many cases on record. 

The most characteristic lesions of the infection are the subcuta- 
neous nodules and abscesses, though cutaneous and visceral lesions have 
occurred; ulcers in the skin which are described as resembling verru- 
cous tuberculosis have formed. Fistulous openings connecting with 
deeper abscesses occur with local superficial cutaneous lesions about 
their edges. The course of the disease untreated is chronic. 

Histopathology. — The histopathology of the infection has been 
thoroughly studied and found to resemble those disorders classed as 
the infectious granulomata. Blastomycosis, tuberculosis, syphilis, 
and deep-seated coccogenous infections are all simulated. 

The organism is obtained in pure culture from the abscesses in 
six to eight days after inoculation and appears first in round white 
colonies. These later spread, become wrinkled, and dark colored. 
The media for growing trichophyta are suggested by Sabouraud for 
this parasite. It also grows in bouillon in which it may form a veil 
or flocculent down-growth. Microscopically, it occurs as a fine myce- 
lium with long partitions ; oval spores develop a terminal filament 
which is capped by several spores. 

Diagnosis. — The parasite is apparently difficult to find in fresh 
specimens differing considerably in this respect from blastomycosis, 
a disease it closely resembles in many particulars. The positive proof 
lies in the cultural findings. 

Treatment. — Potassium iodide appears specific in its management. 
Surgical intervention may be indicated in large abscesses. 

Prognosis. — The prognosis in the disease when recognized is good. 

DISEASES DUE TO ANIMAL PARASITES. 

The human skin may be attacked by animal parasites which (a) 
habitually exist upon or within the integument, securing their nutri- 
ment in these situations; (b) exist upon the clothing, furniture, or 
other articles of environment of the body, attacking the latter only 
when in search of food : (c) are brought accidentally into contact with 
the human body and attack it when irritated or alarmed without seek- 
ing nutriment ; or (d) infest the vascular channels or viscera of the 
body and involve the skin only when approaching the surface as an 
accident of the human invasion. 

Some parasites are sexually mature ; others only in the larval con- 
dition. Few of the entire list confine their attacks to the human 
body, the most afflicting other animals as well as man. 3 

ilnd. Med. Journ., 1899, p. 272. 

2 Annates, 1903, s. iv., iv., p. 678. 

3 Braun, M., Animal Parasites. New York, 1906. 



SCABIES. 835 

SCABIES. 

(Lat., scabere, to scratch.) 

("The Itch." Fr., Gale; Oer., Kratze. 
Parasite: Sarcoptes Scabiel, Acarus Scabiei.) 

Scabies is a contagious cutaneous affection in which multiform 
lesions (papules, vesicles, pustules, excoriations, crusts) occur upon 
the axillary folds, the hands (especially the interdigital spaces), the 
wrists, the abdomen, the upper thighs, and in infants often also the 
face and feet, characterized by intense pruritus with nocturnal ag- 
gravation, and due to the presence of Acarus scabiei. 

Symptoms. — Scabies is a disease of polymorphic symptoms, which 
may be viewed as an artificial eczema or dermatitis, produced by the 
invasion of the itch-mite (Fig. 168). The objective symptoms differ 
according to the extent to which the skin is primarily invaded by the 
parasite, or is secondarily injured by traumatism and severe scratch- 
ing of its surface. 

Prominent among the objective symptoms is the cuniculus, or acar- 
ian furrow, an elongated gallery excavated in the epidermis by the fe- 
male acarus soon after her impregnation by the male. The male 
does not enter the skin, but is lodged beneath the crusts or other exu- 
viae which gather upon its surface. This cuniculus, or furrow, is a 
whitish or a yellowish, slightly arciform, linear lesion, with regular 
parallel borders covered with dots or specks of blackish aspect, rep- 
resenting fseces of the mite. ' The furrow (Fig. 169) terminates at the 
upper extremity by a vesicle, pustule, or exfoliation of the surface at 
the site of an infundibuliform depression ; and at the deeper extremity 
by a whitish and yellowish, shining and salient point, representing 
always the acarus. This is the most characteristic symptom of scabies. 

The " head " of the gallery, where the parasite first entered the 
skin, is usually whitish, and is more elevated than the " tail," where 
the acarus rests after laying its dozen or more of eggs. At times the 
entire cuniculus forms an elevated ridge, rather than a thread-like de- 
pression, with white dots along its summit. When the roof of the 
vesicle at " the head " is torn off by scratching the effect is to produce 
a reddened spot at its site, surrounded by a whitish moat running 
around the entrance of the gallery. 

When the burrow exists it can be recognized most perfectly in the 
interdigital spaces and on the skin of the penis as a tangential line, 
running from a vesicle, papule, or pustule to a distance of from one- 
eighth of an inch to an inch. It resembles a beaded, dotted, yellow- 
ish or blackish thread, the color being more pronounced in comparison 
with a fresh-colored and washed skin, and less marked in contrast with 
a soiled surface; being, in a soiled and subsequently washed integu- 
ment, most conspicuous in proportion as the small puncta have served 
to entrap particles of dirt. The cuniculus may be curved, angular, 
or tortuous ; and occasionally may be seen well-nigh completely cover- 
ed by a bulla, pustule, or vesicle extending its entire length. In 



836 



PAEASITIC AFFECTIONS. 



these cases, however, the female always penetrates beyond the periph- 
eral wall of such lesion, working her gallery beyond it and more 
deeply, lest she be lifted by the exudation out of reach of the succulent 
rete where she feeds. 

Hebra points to the fact that between two parallels, one drawn 
through the nipples and another at a short distance above the knees, 

Fig. 168. 




Female acarus fecundated (ventral surface). An ovum arrived at maturity is visible 
within the body. (After Kaposi.) 



on the anterior face of the body, can be recognized the greater part 
of the eruptive lesions in every case of scabies. 

The disease is indeed one peculiar to those classes which are the 
familiars of filth and poverty, occurring among these at all ages and 
in both sexes. As a matter of accident, it may appear, though rarely, 
in individuals of high social station. It is much more common in 
Scotland, Austria, Prussia, Sweden, Norway, France, and the Orient, 
than in America. During the late Civil War it prevailed with rela- 
tive frequency among the masses of Americans associated in regiments 
with foreigners who had been but a short time in the country; and 
steadily decreased after that time. But few cases until lately were 



SCABIES. 



837 



seen annually in the public clinics of our large cities, though here and 
there, chiefly among newly arrived immigrants, isolated groups of 
cases of the disease were 



discovered. The influx of 
immigrants to the United 
States, however, in the 
last few years, has brought 
the disease again into 
prominence by reason of 
its greatly increased fre- 
quency. 1 

In consequence of the 
irritation produced by the 
parasite and the trauma- 
tisms by scratching, the 
region invaded may exhibit 
all the symptoms of acute 
and chronic dermatitis in- 
cluding vesicles, pustules, 
wheals, small papules, hy- 
peremia of the skin upon 
which these rest; crusts 
formed by dried serum, 
pus, and blood; excoria- 
tions, fissures, and, in 
cases of long standing, 
pigmentation of the skin 
where the disease has ex- 
isted. These lesions may 
coexist, several appearing 
at the same time upon the 
skin of an affected indi- 
vidual; small vesicles and 
pustules, with perhaps a 
few short cuniculi visible 
upon their summits ; excor- 
iations; larger and longer 
cuniculi interspersed be- 
tween inflammatory pap- 
ules; a tumid skin, evi- 
dently the seat of a mild 
grade of dermatitis ; and 
crusts here and there, be- 
neath which male and 
young acari are ensconced 




Acarian furrow, from the lumbar region. The 
female acarus is visible at the terminal extremity 
of the furrow with ventral surface exposed, and 
containing a mature ovum ; two ova, next her, 
have been laid during the day ; the third exhibits 
traces of the embryo ; the twelfth exhibits a ma- 
ture larva (a) : twelve empty shells are also 
seen ; between these the feces are represented by 
black points. (After Kaposi.) 



such is the composite picture of a typical eruption in scabies. 
It will be remembered that the acarus family find nutriment, shel- 

A-mer. Jour. Med. Sci., 



1 Cf. Hyde, Scabies in the United States and Canada 
Mar., 1905. 



838 PARASITIC AFFECTIONS. 

ter, and all they require on the person of the individual whose skin 
they inhabit, and there is no inducement for them to colonize at the in- 
stant of the first opportunity offered. The transfer of a male acarus 
alone, from one person to another, would not insure a generation of the 
young; and the unimpregnated female could not alone do more. As 
for the impregnated female, Hebra, on several occasions, failed to in- 
duce scabies when one such female only was transferred intentionally 
to a sound skin and was seen to penetrate it. -Lastly, the eggs alone 
would not suffice, for they have to be nicely planted within the epi- 
dermis in order to be hatched safely to maturity. In brief, only the 
more intimate contacts of the bed at night, and the application of 
nails charged with acari of both sexes, especially the young, are to be 
regarded as most effective for the transmission of the disease. This 
fact explains why nearly seven men are found to be affected with 
scabies to one woman. Women, as a rule, are more inclined to sleep 
alone, or with those only to whom they have family ties ; while labor- 
ers, boys, apprentices, and persons of that class, including those who 
are strangers to each other, at times occupy the same beds, especially 
in large cities, where they are often huddled together at night like 
swine. 

The female acarus may be recognized always at the terminal ex- 
tremity of her gallery, for it is now known that she does not in her 
lifetime leave it for any purpose, as was at one time taught. The in- 
truder here shows as a minute, whitish, clearly defined dot, presenting 
a contrast in this particular with the blackish feces in the gallery be- 
hind, and may in a good light, by a person of some dexterity and fair 
eyesight, be extracted on the point of a cambric needle from her lodg- 
ing-point. It is important to know that this parasite may be recog- 
nized by the unaided human eye. Its characteristic tortoise-like body 
exhibits most of its anatomical peculiarities under a glass enlarging 
the figure but one hundred diameters. 

The regions affected by the eruption are the sides and roots of the 
fingers and toes; the flexor aspects of the wrist-joints; the feet (and 
especially in women, the delicate skin of the feet near the instep, 
partly dorsal, partly plantar in situation) ; the palms (especially of 
women and children) and the dorsal surfaces of the hands ; the but- 
tocks (more particularly in those who are seated in the trades and 
occupations of life) ; the extensor faces of the joints; the belly; the 
penis and scrotum in men ; the anterior folds of the axilla? ; the nip- 
ples and breasts of women; the elbows and knees, rather than the 
popliteal space and bend of the elbow ; and the anal region. Scabies, 
prurigo, and pruritus are alike in this, that in each the face and pos- 
terior aspect of the body display the fewest of any lesions visible. In 
general, portions of the body subjected to constant pressure by the 
clothing, as, for example, the regions pressed by the corset of the 
woman and the waistband of the trousers in man, are sites of predilec- 
tion. In other cases the disease is encountered in the axillae, the 
groins, and, as a matter of rare exception, over the entire surface of 
the body. 



SCABIES. 839 

Eaehlmann 1 describes a blepharitis due to scabies, producing a fall 
of the eye-lashes. The acarus lodges in the ciliary follicles. 

The itching of scabies is occasionally severe, and has, in fact, con- 
ferred upon the disease its familiar English title, "the itch." This 
sensation is usually worse at night, when the parasite is rendered 
active by the heat of the body in bed, retained by the bed-clothing. 
It differs somewhat in different cases, being at times the cause of but 
little complaint. There is nothing characteristic, however, in the oc- 
currence of this symptom, as equally severe pruritus accompanies ec- 
zema unconnected with parasites. 

The itching which results from the epidermic tunnelling in prog- 
ress is often noticeably more severe than would be suggested by the 
moderate number of skin-lesions visible. When these lesions (puncta, 
vesicles, pustules, blebs, papules, resulting crusts, furrows, excoria- 
tions, etc.) are found upon the hands the itching becomes so great 
that the infested person scratches also the accessible parts of the 
skin, where there were originally no acari, such as the inner side of 
the thighs, the lower belly, etc., as Hebra suggests, simply because 
they are "handy." Hence it is that the picture comes to resemble 
that of all pruritic and scratched skins. 

Several artificial forms of this polymorphic affection are noted 
occasionally. In infants the face may be invaded after contact with 
the breast of the mother, or the buttocks after contact with the flexor 
aspect of the nurse's arm. Large vesicles, and even rupioid bullae, 
may result from irritation of the tender skin of children. Again, 
in subjects predisposed to eczema for any reason the invasion of the 
parasite in one region of the body, possibly a region of preference, 
may originate an eczema in another locality whither the parasite has 
not wandered. In other cases the most aggravated forms of eruption 
are seen, usually in persons of filthy habits who have long suffered 
from the malady. Thus, extensive epidermal callosities form, filled 
with debris of dead parasites unable to find nutriment longer in the 
cornified rete ; or extensive greenish and blackish crusts cover colonies 
of acari which survive beneath them for generations of their race. 
The nails in such extreme cases may be involved. 

As a rule, the disease does not advance to severe grades. The 
parasites having gained lodgment in the skin produce characteristic 
symptoms of the disease in the average of cases, and, though un- 
recognized and persisting for weeks, are the sources of so much annoy- 
ance that treatment of some sort is instituted which is apt to restrict 
extension of the malady, certainly in America, within moderate limits. 
Usually after lodgment is effected a week or a fortnight elapses 
before the first characteristic furrow is formed, though the pruritus is 
of earlier occurrence. The extension of the disease by the maturing 
and ravages of young acari requires a few weeks more, so that in the 
course of from two to three months the evolution of the malady may 
be considered complete. In the course of about three months more 
the disease, unchecked, may become generalized. 

^ourn. de Med. Feb. 10, 1900. 



840 PARASITIC AFFECTIONS. 

Even the animal parasites elect the soil upon which they thrive, 
and indeed, after such election, thrive well or ill according to the 
conditions present. This is not only exemplified in the matter of 
individual susceptibility, but in the conditions of health of an affected 
person. Thus, in puerperal and typhoid fevers and other grave 
states of systemic disturbance the parasites perish in the skin and the 
eruption disappears ; classical symptoms may recur in convalescence 
if one or more acari have survived with sufficient vigor to reproduce 
their kind. 

Scabies Norvegica ("" Norwegian Itch") is a title employed by 
some authors to designate a severe type of scabies first described by 
Danielssen and Boeck and later by Fuchs, Bamberger, and others. 
American cases have been recorded by Hessler 1 and Ravogli. 2 In 
this condition there is extensive crusting from desiccation of the exu- 
dation furnished by the severe dermatitis induced by millions of 
mites in all stages of development. Hessler 3 reported a case in which 
the entire surface of the body was covered with large, thick scales, 
which were shed freely and were riddled with acarian furrows. By 
counting the number of parasites in a scale of a given size he calcu- 
lated that the man had upon his person at one time not less than 2,- 
000,000 mites and 7,000,000 eggs. Huebner calls attention to the 
albuminuria which may occur in severe cases. 

Etiology. — Scabies is produced only by the A earns scabiei (or 
Sarcoptes scabiei), and is thus contagious, the parasites being intro- 
duced upon the surface of one individual mediately or immed- 
iately from the skin of another infested man or an animal. Volk 4 
believes that apart from the pyodermia secondary to scabies, there is 
at times a true eczema efflorescence, which he ascribes in part only to 
the excoriations and in part to toxines furnished by the parasites. 
All persons are supposed to be susceptible to the disease, but the diffi- 
culty of intentionally transmitting it by contagion is greater than 
that of inducing the leech to fasten itself indiscriminately upon any 
given skin. The brief shaking of the hand or transient personal 
contacts of the daytime are in many cases insufficient for contagion. 
Few practitioners of medicine suffer after careful examination of 
a patient. When a patient affected with scabies is exhibited at the 
clinic he is minutely and without ill results examined by dozens of 
students. It is probable that the contacts of the night incidental to 
the occupation of the same bed, or the use of gloves and other articles 
of apparel containing parasites or their ova, are essential to transmis- 
sion of the disease. The parasites capable of inducing scabies in the 
lower animals (horses, dogs, sheep, etc.) occasionally are transferred 
to the human subject and are then capable of inducing irritation in 
varying grades. These parasites, however, rarely beget a disorder of 
the grade and intensity following infestation with the human acarus. 
They soon perish from failure to propagate. 

1 Science, Mar. 3, 1893. 

2 Cincinnati Lancet-Clin., July 16, 1898. 

3 Med. News. May 13, 1893. 
4 Arehiv, 1904, lxxii., p. 53. 



SCABIES. 841 

Pathology. — The pathology of the eruption induced by the para- 
site is that of the various phases of exudation. The differences be- 
tween scabies and all other eruptions of similar type depend, in the 
case of the former, upon the peculiarities of the exciting cause of 
the disease. 

Parasite. — The Sarcoptes scabiei (Sarcoptes hominis, Acarus sca- 
biei, Sarcoptes communis) has an oval or nearly orbicular body, whit- 
ish in hue, traversed by interrupted rugae or folds, running for the 
most part at right angles to its long axis. It is provided with trans- 
verse rows of minute bristles on the dorsum, and with groups of 
trichomae on the front, sides, and back. There are chitinous hairs 
at the base of the legs ; the two first pairs being provided with pedun- 
culated ambulacra in both sexes, the two posterior pairs terminating 
each in a long bristle in the female ; in the male, the third pair of 
legs terminate in a bristle, the fourth pair with a pedunculated am- 
bulacrum. The anus lies at the posterior border of the dorsum. 
The male is 0.2 to 0.3 mm. in length, and 0.145 to 0.19 in breadth; 
the female is 0.33 to 0.45 mm. in length and 0.25 to 0.35 in breadth. 
The tunnels contain the excrement and ova, the latter measuring 
0.14 mm. in length. The males commonly perish after copulation; 
the females only after the ova are all excreted. Six-legged larvae 
hatch out in four to eight days, slough the skin three times, and then 
are prepared to burrow (Braun). 

The female alone penetrates the epidermis. This act she accom- 
plishes by inserting the head first into the tissues of the skin, the 
body disappearing afterward, and depositing behind, in the course 
of her progression downward one or two eggs daily until from twenty 
to fifty have been laid. The eggs are oval, their longitudinal axes 
placed transversely to the cuniculus. In the two or three eggs found 
nearest the female only a yellowish color can be distinguished ; in the 
third to the fifth, traces of the embryo are recognizable ; the sixth to 
the ninth contain larvae; and in the oldest the head and front legs 
can be discerned. When mature the shell of the ovum is ruptured, 
usually between the third and sixth day, and the young acarus reaches 
the surface of the skin either by making exit at the original point of 
entry of the mother or by rupture of the roof of the burrow. It sub- 
sequently buries itself in the skin for a brief time while the process 
of casting its slough is completed. The acarus survives but a few 
days when removed from the skin and immersed in liquids which 
protect it from the air, such as water, oil, etc. 

Sarcoptes scabiei equi, ovis, caprae, cameli, auchenii, suis, canis, and 
vulpis. — Other families of sarcoptes, or acari, infest the lower ani- 
mals such as the horse, sheep, goat, swine, dog, wolf, fox, and also 
fowls, in which the female only burrows into the skin and there de- 
posits ova. Very rarely indeed these are transferred to the skin of 
man and then commonly soon perish with the result of producing 
merely a temporary disorder. According to Besnier, 1 in one case 

1 Annales, 1892, s. iii., iii., p. 623. 



842 PARASITIC AFFECTIONS. 

the entire body of a man was infested, including the face and scalp, 
after transmission of the parasite from a horse. 

Bosselini 1 describes two cases of scabies in an old man and a boy, 
contracted from an ass. The eruption principally affected the ex- 
tensor surfaces of the arms and the trunks ; there were no intermed- 
iate lesions. In the case of a man who contracted the disease from 
scraping a hog with pruriginous affection of the skin, a generalized 
eruption followed similar to that seen in the other cases, the animals 
when examined being infested with acari. Artificial transmission of 
the disease to a child in the hospital resulted in urticaria without dis- 
covery of burrows or acari. 

Placal, 2 observed nine cases in which there was a desquamating 
erythema in patches, produced by an acarus obtained from the larva 
of the moth which infested barley. The patients had been engaged 
in handling the grain. 

Other observers have recorded cases where a non-burrowing acarus 
has invaded the skin and produced more or less evidences of pruritus 
followed by scratching and infection. 

Diagnosis. — The diagnosis of scabies must rest upon the recog- 
nition of its special features described above. There are no lesions 
peculiar to the disease save the cuniculi, or furrows, made by the 
parasites, and they, it will be remembered, do not appear until one 
or two weeks have lapsed after infestation. They may also be obliter- 
ated or be concealed by excoriations when the finger-nails plough 
them open, or by pustulation and subsequent crusting when the irri- 
tation induced is excessive. In every well-marked case, however, 
cuniculi can be discovered, if not on the fingers, wrists, or forearms, 
at least on the penis, the breast near the nipple, or upon some other 
covered portion of the body. With care and a little dexterity a fine 
cambric needle can then be forced into the furrow well down to and 
a little beyond its remote cul-de-sac, and the fons et origo malorum 
be thence extracted and placed under the objective of the microscope. 

Next to the cuniculus and its inmate or inmates, the two most 
important diagnostic features of scabies are the polymorphism of the 
eruption and the sites of its most frequent occurrence. These sites 
may be described as the most important of the two. Few skilled 
diagnosticians would fail to entertain a suspicion of scabies in a case 
of supposed "eczema," existing upon the fingers, wrists, and penis 
only, or upon the breast of a mother, and the face and buttocks of 
her infant, or the arms of its nurse. 

It is important to remember that eczema is often attended with 
very severe itching; that this sensation may be intensely aggravated 
after retiring to bed at night ; that eczema is often limited to the 
hand; it is not rarely characterized by interdigital vesicles and pus- 
tules ; and is, indeed, in America much the more frequently encoun- 
tered of the two diseases. The popular conception of scabies holds 

1 Giorn. Ital. delle Mai. Ven. e della Pelle, 1905, Fasc. 1, p. 64. 

2 Annales, 1900, s. iv., i., p. 947. 



SCABIES. 843 

to the belief that the disease is exceedingly common ; that every severe 
itching with a cutaneous exanthem is produced by " insects " or 
"worms" in the skin, and that transient casual contacts are abun- 
dantly capable of transmitting the offending parasite. Many more 
cases of simple eczema are supposed to be scabies than the reverse. 
There are few villages in this country which cannot lay claim to an 
" itch," often known by a name of local significance. Among these 
provincial titles may be counted the "prairie itch" of the West. 
These affections are, as a rule, forms of eczema quite unconnected 
with the existence of a parasite, and incurable generally by the para- 
siticides too often employed to "kill" the disease. In all such in- 
stances the absence of the characteristic features of scabies described 
above, the absence of a history of contagion, and the presence of an 
alternating relief and aggravation of the symptoms, will point to 
the character of the malady. In the severe pruritic affections of 
the West and the Northwest of America, described in the chapter 
devoted to the several forms of Pruritus, it is noticeable that the pa- 
tients are often cleanly — those who are careful as to the hygiene of the 
body. Scabies is often a filth-disease, and is as a rule recognized 
among the filthy classes. Of diagnostic importance is the relative 
rarity of scabies among other cutaneous affections, pruritus included, 
observed in the United States. 

The Statistical Committee of the American Dermatological Asso- 
ciation from July 1, 1877, to January 1, 1898, reported 318,500 
cases of skin-diseases of all kinds occurring in the United States and 
Canada. Of this number, 11,560 were instances of scabies, a per- 
centage of 3.66 to the total number of affections tabulated. The in- 
fluence of temporary increase of population and the crowding to- 
gether of persons in large centres, many of whom came from foreign 
countries, is well illustrated by the statistics of scabies. 

Treatment. — The treatment of scabies has in view the destruction 
of the parasite and the relief of the cutaneous disorder which the 
former has induced. Ordinarily these two indications are fulfilled 
at the same time. The destruction of the parasite is usually followed 
by relief of the resulting cutaneous lesions ; and the skin, freed from 
the burrowing acari, is no longer tormented by the scratching, which 
in extreme cases is not only irresistible, but is also an important ele- 
ment in the aggravation of the lesions. In other cases, however, the 
resulting dermatitis persists after removal of the original cause of 
the disease, and it demands special attention. Care should always 
be had to avoid treating the delicate skin of the infant with the 
severer remedies efficacious upon the thicker integument of the adult. 

Sulphur, in all its forms and various combinations, has long held 
the highest esteem in the treatment of the disease. Other remedies, 
however, of acknowledged efficacy are employed with satisfactory re- 
sults, most of them owing their usefulness to the strong odor they emit. 
Among these remedies may be named carbolic acid, petroleum, naph- 
tol, the oils of cloves, cinnamon, rosemary, and mint; tar, balsam of 



844 PARASITIC AFFECTIONS. 

Peru, and balsam of tolu; styrax, staphysagria, Vleminckx's solu- 
tion (heretofore described), and sapo viridis. 

Sulphur is commonly employed in the form of an ointment, 1 to 2 
drachms (4.-8.) to the ounce (30.), thoroughly rubbed, first into the 
affected patches, especially between the individual fingers (or toes), 
about the wrists, over the palm and dorsum of the hand, into the 
axillae, about the nipples, penis, buttocks, or other invaded parts, and, 
finally, over the cutaneous surface in general, the head alone excepted. 
If no severe eczematous complications exist, the inunction is well pre- 
ceded by a warm soap or a warm sof t-soap-and-water bath ; but in the 
event of such complication the bath should be deferred as decidedly 
injurious in the inflamed condition of the skin. 

The first inunction is preferably performed at night, after which 
the patient retires to bed enveloped in woollen underclothing or 
wrapped in a blanket. It is neither wise nor necessary to induce 
sudation by these measures, for the skin is best retained in simply 
a greasy condition unmacerated by sweat. In England it is custom- 
ary to bathe on the ensuing morning, but it is preferable to defer the 
bath until the cure is complete, however disagreeable the condition 
of the integument may be to the sufferer. The sulphur-inunctions 
are thus repeated for three successive nights, a thorough warm water- 
and-soap bath being finally employed for the purpose of cleanliness. 
The clothing meantime should either be thoroughly disinfected with 
sulphur, be immersed in boiling water, or be subjected in a stove or 
furnace to a dry heat capable of destroying all acari and ova which 
may adhere to it. 

In France, the routine treatment of scabies is always preceded by a 
thorough friction for twenty minutes with soft soap, special attention 
being as usual directed to the invaded areas. This operation is at 
once followed by a bath in warm water, during which the surface is 
also thoroughly scrubbed for from thirty minutes to an hour. Lastly, 
the parasiticide is well rubbed on for fifteen minutes, the patient is 
redressed in the underclothing (disinfected during the progress of 
the bathing), and the final cleansing of the skin with water is prac- 
tised within twenty-four hours. 

When a resulting dermatitis demands attention, it is to be treated 
in accord with the general principles considered in the chapter de- 
voted to that subject. In this case the dusting-powders, the oleated 
lime-water, and the zinc, diachylon, and even more stimulating oint- 
ments, may be employed with advantage. Generally, after a vigorous 
course of external treatment with sulphur, the patient should be in- 
structed to defer any further topical applications to the skin for a 
week or more, in order to test the efficacy of the method pursued. 

Sherwell 1 finds sulphur in powder as efficacious as in ointment and 
less disagreeable. He directs the patient, after a soap-and-water 
bath, to rub gently over the body half a teaspoonful of sulphur lotum, 
and to dust the same amount between the sheets of the bed occupied 

1 J. C. T>., 1899, p. 494. 



SCABIES. 



845 



at night. The bath, the powdering of the body and bed, and a change 
of clothing are repeated every two or three days. In the average case 
one week of such treatment is sufficient. 

One of the following formulas may be substituted for the ordinary 
sulphur ointment: 



^ Sulphur, flor., 3xij; 48 

Potass, subcarb., 3vj ; 24 

Aclipis, 3ix; 270 

Hardy's modification of Helmerich's ointment. 



5 


Styracis liq., 




f5j; 


4 






Petrolei, \ 
01. olivae, { 


a a 


f^ss; 


aa 15 1 




Balsam. Peruv., 




f3ijss; 


101 




Spts. sapon. virid., 




f3v; 


20| M. 
[Kaposi.] 


$ 


Potass, sulphurat., 




3v; 


20 






Sapon. alb., 




3xx; 


80 






01. oliv., 




f3iv; 


16 






01. thym., 




gtt. xv ; 


1 


M. 










[Jadelot.] 


s 


Sulphur, sublim., 1 
Balsam. Peruv., ) 


aa 


3ss; 


aa 2| 




Adipis, 




S; 


30| M. 


Fo 


r use especially in the scabies of children. 









[Duhring.] 

Hebra's modification of Wilkinson's salve, Vleminckx's solution, 
and balsam of tolu are employed for the same purpose. 
Kaposi's naphtol formula is: 



]£ Naphtol., 

Sapon. virid., 
Cret. alb. pulv. 
Axung., 



15 parts; 

50 parts; 

10 parts; 

100 parts. 



M. 



McCall Anderson much prefers, on account of its pleasant aroma : 

301 



Jfc. Styracis liquid., 

Adipis, 
Melt and strain. 



3u; 



M. 



or Schultze's modification of Pastav's formuk 



^ Styracis liquid., 
Suts. rectificat. 
01. olivse, 

Ft. liniment. 



ni; 


30 


f3ij; 


8 


f3j; 


4 



M. 



A saturated solution of sodium hyposulphite may be used at night, 
followed in the morning by the application of one part to four of 
dilute hydrochloric acid. Vlademir de Holstein praises the tincture 
of benzoin. Jullien prefers to all other remedies Peruvian balsam. 

Prognosis. — Scabies is a curable disease, even after persistence for 
long periods of time. When, however, complications exist, or severe 



846 



PARASITIC AFFECTIONS. 



eczema continues after the efficient action of a parasticide, the patient 
may experience delay before attaining complete restoration to health. 



Fig. 170. 



DEMODEX FOLLICULORUM. 

(STEATOZOON, OR AcARUS FOLLICULORUM. Ft., AcARE DES FOL- 

licules; Ger.. Haarsackmilbe.) 

This parasite was discovered in 1841 by Henle. It is a micro- 
scopic creature in the form of an elongated and jointed worm, with 
head separated from the thorax, and eight legs, four on each side, 
each leg with three articulations, and terminating in three small 
hooklets. The posterior extremity of the body is a vermiform ap- 
pendage, terminating in a conical point (Fig. 170). 

The Demodex folliculorum is found long after birth upon the free 
surface of the integument, those parts of the skin particularly where 
the sebaceous glands are large, and on patients affected with acne or 
seborrhoea oleosa, as well as upon those free from all evidences of 
disease. It is encountered also in the substance of 
the comedo-plug, where at times from five to twenty 
may be discovered in a single follicle. A demodex, 
which is considered to be a variety of that discovered 
upon the skin of man, infests dogs, mice, and other 
lower animals ; and may in the latter be the source of 
disease characterized by furuncular lesions, abscess, 
and even fatal results. None of these parasites is, 
however, known to be transmissible to man. 

De Amicis, 1 Majocchi 2 and Dubreuilh 3 report 
cases of pigmentation of the skin due apparently to 
this parasite. The case reported by Dubreuilh was 
that of a woman forty years of age. The lips, cheeks, 
other portions of the face, the mammary surfaces, and 
chest were the seat of light, yellowish spots where the 
demodex was discovered in great numbers. The sur- 
face was somewhat rugous, due apparently to a pe- 
culiar whitish substance, resembling rice-grains, ac- 
cumulated about the follicular orifices, twelve or more 
parasites being visible in each field examined. The 
patient of De Amicis was twenty-seven years of age, 
the face presenting a cafe-au-lait hue over the lips 
and chin. Majocchi's was a male patient whose dis- 
coloration occurred in the form of a brownish zone 
surrounding a patch of atrophic lupus. The most effective treatment 
is by the use of shampooings with green soap. 

1 Giorn. ital., 1898, iii., p. 205. 

2 Ibid. 

3 Journ. de Med. de Bordeaux, No. 4, January 27, 1907. 



m 



Demodex follicu- 
lorum. 



PULEX IBEITANS. 847 

PULEX IRRITANS. 

(Flea. Fr., Puce commune; Ger., Gemeiner Floh.) 

Fleas exist in all parts of the world, the pest which especially 
attacks man living in dwellings as well as out of doors, infesting 
crevices in floors, walls, and even the clothing. Fleas belong to the 
order of diptera; family Aphaniptera, the males being 2-2.5 mm. in 
length; the females about 4 mm. The insects are reddish-brown in 
hue ; are provided with a head having no bristles which, however, well 
projected backward, mark its thoracic and abdominal rings. The 
eggs are white and barrel-shaped and are deposited in the crevices 
inhabited by the mature insects as well as on the clothing of men. 
The legless larvse having fourteen segments are changed to pupee in 
eleven days. 

The flea which specially attacks man has a laterally compressed 
body, an oral haustellum, serrated soft mandibles, a tongue sheathed 
in an inferior labium, and a pair of labial, four-jointed palpi. Each 
of the triple segments of the thorax bears a pair of five-jointed, double- 
clawed legs. The nympha is enfolded in a cocoon, but only the ma- 
ture insects prey upon man. According to Geber, the insect injects 
an irritating fluid into the skin at the moment of attack. The lesion 
it produces is a hemorrhagic punctum, followed by a transitory hyper- 
emia and a hemorrhagic exudation which may persist for a few hours. 

The central punctum, or point, distinguishes the wound produced 
by the insect from macules of simple erythema ; but care should be 
taken when fever is present to exclude the symptomatic erythemata. 
The site of the wound may become an urticarial wheal. 

The flea now shares with the mosquito and the bed bug the odium 
that attaches to the media of transmission of disease. Lauder- 
Brunton 1 has called attention to the fact that rat-fleas are capable of 
transmitting the germs of the plague from rat to man and even of 
starting epidemics in communities where isolated cases of plague had 
been supposed effective. 

The flea attacks the human skin for the purpose of securing its 
blood-food ; and when the pests are numerous the resulting distress is 
considerable, the wounds being recognized by a central punctum with 
an areola of reddish or purplish hue. Urticarial lesions are produced 
in sensitive skins by the effort to relieve the pruritus produced by the 
bites of the insects ; and in severe cases the nervous system is harassed 
to a grave point by the resulting discomfort. The petechial charac- 
ter of the cutaneous lesions is often well marked. 

It is important to identify flea-bites on the skins of patients sus- 
pected to be the victims of typhus or other fevers ; and in filthy sub- 
jects who are affected with other skin disorders. 

Mixed cases of flea-bites with wounds produced by bugs and lice 
are often seen in the lowest classes applying for relief to public 

1 Lancet, 1907, November 9. See also: J. A. M. A., 1907, xlix., p. 2156 
(British Plague Commission in India) : and Moorhead, The Military Surgeon, 
1908, Mar., p. 165. 



848 PAEASITIC AFFECTIONS. 

charities; and the deeply pigmented skins they exhibit, often with 
purpuric lesions distributed over the lower extremities, and com- 
mingled with syphilitic eruptions, are in the highest degree con- 
fusing. The practitioner should always be on his guard in pronounc- 
ing on these cases, especially if the purpuric blotches occur in the 
cachectic or in those suffering from other diseases than those of the skin. 

The fleas of the lower animals occasionally are transferred to the 
human body, but rarely thrive on such a host. 

Treatment. — The treatment of flea-bites is by carbolized, alkaline, 
and tarry lotions. Stelwagon recommends the wearing of bags filled 
with gum-camphor or pyrethrum beneath the clothing. Sulphur has 
been employed similarly. 

CYSTICERCUS CELLULOSE CUTIS. 

Cysticerci have been recognized in the skin and subcutaneous tis- 
sues by Rokitansky, Guttmann, Schiff, Ferreol, Duguet, Lewin, 1 and 
other observers. The subjects are usually consumers of uncooked 
meats, especially of pork. In these cases one or many oval or round- 
ish, firm, elastic, cutaneous or subcutaneous, pea- to walnut-sized 
tumors, isolated or disseminated, unproductive of pain, project from 
the general level and are enveloped by an unaltered integument. 
They occur upon the trunk and the extremities. They remain 
in this condition without change for years and may accompany 
cysticerci of the brain and other portions of the body produc- 
tive of the serious disturbance of the economy which such in- 
vasion may determine. If the skin-tumors be opened and their con- 
tents examined, the parasite (which is the scolex or hydatid of taenia 
solium) will be recognized as an ampulliform sac, with a cephalic 
appendage, reentrant or projecting, and provided with four suckers 
and a coronal of hooklets. By no external characteristics could such 
tumors be distinguished from others of similar size and external ap- 
pearance. Only in the rare cases of nervous complication could a 
suspicion arise based upon the real character of the disorder. Re- 
specting this matter, however, the diagnostician is in no worse posi- 
tion than when called upon to recognize cysticerci of the viscera. 
Cysticerci of the liver are distinguished during life and subsequently 
removed by operative procedures. 

Diagnosis. — The diagnosis is from gumma, lipoma, epithelioma, 
and sarcoma. The first occurs only in the syphilitic ; the second has 
a peculiarly uneven surface and firm feeling; the third is largely 
facial in situation ; and the last is of a malignant character and rela- 
tively rapid career. 

ECHINOCOCCUS. 

Weyl and Geber state that the parasite, Echinococcus (larva or 

hydatid of the taenia echinococcus of the dog), is found in the human 

1 Cf. Vierteljh. f . Derm. u. Syph., 1894, vol. xxvi., pp. 70 and 271, for review 
of literature. 



LEPTUS. 849 

skin. Of 336 cases reported by Davaine, the parasite occurred thirty 
times in muscular and subcutaneous tissues, more often in women 
than in men. The softish, fluctuating tumors or vesicles produce a 
disagreeable sensation of tension, and they undergo fatty or other 
metamorj)hosis after the death of the encapsulated parasite which usu- 
ally occurs in from one to two years. Exploration of the superficially 
seated, fluctuating tumor, covered with unaltered integument, usually 
demonstrates its nature. 

DISTOMA HEPATICUM. 

Kiichenmeister 1 reports three instances in which the embryos of 
the large liver-fluke were encapsulated in subcutaneous tissue. The 
tumors were painful or painless and occurred on the head, trunk, and 
extremities. 

LEPTUS.2 

(Leptus autumjstalis, Harvest-bug, Mower's Mite. 
Fr., Rouget; Qer., Erntemilbe.) 

The Leptus (Figs. 172 and 173) is a minute, reddish or yellowish- 

Fig. 171. 




Leptus americanus. 

red insect of the family Trombidm, visible to the naked eye, and 
found in summer and autumn clinging to bushes and grasses. It is 
found both in America and in Europe. It attacks man only after its 

1 Loe. eit. 

9 Cf. William MacLennan, The Leptus Autumnalis and its Skin Lesion, Lancet, 
1905, p. 1765. 
54 



850 



PARASITIC AFFECTIONS. 



accidental location upon the skin, where it perishes in the course of a 
few hours. In such situations, however, it induces considerable irri- 
tation, betrayed in erythematous, urticarial, papular, and eveneczema- 



Fig. 172. 




Fig. 173. 




Leptus. (After Kuchenmeistek.) 



Rouget. 



tous symptoms, accompanied by pruritus of various grades. The 
parts chiefly affected are the ankles, legs, arms, and feet. The mite 
may be seen in the skin as an orange-reddish or brick-reddish point, 
which represents often the body of the insect, its head being buried in 
the aperture of a follicle beneath. Examined after extraction, it is 
seen to have a relatively large cephalic extremity. It has a short, 
cylindrical and conical haustellum, composed of fused double max- 
illae; and two strong, hooked, five-jointed palpi, which can be rolled 
up. There are also two hatchet-like mandibles. It has a well- 
rounded or oval body 0.3558 mm. long and 0.32 mm. broad, provided 
with three pairs of legs. It is found upon the lower limbs, and also 
upon the scalp and over other parts of the body. According to 
Duhring, children are especially liable to its encroachments. The 
disorder is relieved by the application of balsam of Peru in olive-oil, 
carbolated oil, spirit of camphor, or other mild stimulant or para- 
siticide. 

There are several species of leptus (Leptus americanus, Leptus 
irritans) and other insects living on shrubs and grasses that, especially 
in the months of July and August, attack the human skin. 

Leptus americanus (Krithoptes monunguiculosus, Fig. 171) is 
named by Weyl and Geber as the larva of a mite that annoys laborers 
in barley. It is yellowish white, oblong or oval in form, averaging 
0.022 mm. in length. There is a protrudible tubular haustellum, 
enclosed by serrated mandibles. On each side are five-jointed palpi. 
There are four pairs of feet — two on the cephalo-thorax ; two, abdomi- 
nal in situation — all articulated to the epimeres. The tarsus of the 
first part terminates in hooked claws ; the others have haustellum 
disks on stems. Between the first and second pairs are swinging 
clubs, indicating the larval condition. 



BROWN-TAIL MOTH. 



851 



BELOSTOMA. 

Schaefer reports irritating effects produced by the sting of the 
American Belostoma ("electric light bug"), a brownish-black insect 
about five centimetres in length attracted in the summer months by 
the light of the electric globes in cities. The insect has two pairs of 
wings and large front extremities armed with claws for the seizing 
of its prey. Four other legs are thickened and flattened for loco- 
motion in water. It possesses a dagger-like prolabium and is pro- 
vided with poison-glands furnishing the secretion by which it destroys 
its victims. 

BROWN-TAIL MOTH. 

In some of the New England states, notably Massachusetts, New 
Hampshire, and Maine, an exceedingly annoying dermatitis for sev- 
eral years has been recognized as the result of the introduction of the 
Porthesia (or Liparis) chrysorrhcea (the brown-tail moth) into cer- 
tain infected districts. More recently the recognition of the disease 



Fig. 174. 




Section showing inflammatory 

changes in the corium 24 hours after 
the skin had been rubbed lightly with a 
small brown-tail caterpillar. (Tyzzer.) 




Section of a caterpillar showing the 
nettling hairs as they are developed 
upon its skin. (Tyzzer.) 



elsewhere, even in some of the Western States, has attracted special 
attention to its etiology and pathology. 1 

Symptoms. — The reaction of the human skin to the "nettling 
hairs" of the moth varies greatly in different conditions and with 
different individuals. In general, there is produced within twenty 
minutes after contact, a more or less severe pruritus followed by an 
urticarial wheal the dimensions of which for the most part corre- 

1 Tyzzer; Journ. of Med. Besearch, 1907, No. 97, March, p. 43; (also by the 
same author, VI. Intern. Cong. Derm., New York, 1907) full bibliography and 
illustration of "nettling hairs" embedded in corpuscles of mammalia. White, 
J. C, Bost. Med. and Surg. Jour., 1901, cxliv., p. 599; Meek, E. K., ibid., p. 657; 
Fernald and Kirkland Bull. Mass. State Board of Agriculture, 1903. 



852 



PABASITIC AFFECTIONS. 



spond to the area of inoculation. When the offending caterpillar is 
crushed on the human skin a more or less severe dermatitis results. 
When infected clothing is worn a diffuse urticarial rash may follow ; 
again, minute discrete papules or vesico-papules of the same size may 
develop. The eruptive symptoms most often occur when the cater- 



Fig. 176. 




A sketch showing the effect of the nettling hairs of the brown-tail moth upon 
mammalian red-blood corpuscles. (Tyzzer.) 



pillars are maturing, in the months of May and June ; but the lesions 
may he seen earlier or later, and even at any season of the year as 
the result of incautious wearing of infected clothing. 

Etiology and Pathology. — Tyzzer has demonstrated that the dis- 
ease in man is produced by penetration of the epiderm, and even of 
the corium, by sharply pointed, barbed " nettling hairs " developed 
on the caterpillar or the moth but found also on cocoons, ova, and 
imagines. These filaments are barbed for their entire length and 
average .1 mm. in length and .004 to .005 in width. They possess a 
thin ehitinous wall with a finely granular material filling the shaft. 

The barbs of the moth do not produce the resulting dermatitis 
as a consequence of the mechanical irritation set up by their presence, 
but possess in addition an irritating substance of a chemical nature 
demonstrated clearly by the reaction it is capable of inducing in red 
blood corpuscles. The pathological process in the skin consists of a 
necrosis of the epidermal cells around the foreign body. Similar 
reactive effects have been produced after artificial infection of mice. 

Treatment. — The treatment is unsatisfactory in consequence of 
the actual penetration of the barbs into the integument. Soothing 
lotions and salve are often ineffectual. Excision of the barbs when 
these can be recognized has been found effective. 



IXODES. 853 

IXODES. 

(Wood-tick. Fr., Pou de Birs, Tique ; Ger., Hoezbock.) 

Several species of tick are recognized, such as the Bhipicephalus 
annulatus (cattle-tick), Amhlyomma americanus, Ixodes unipunc- 
tatus, and Ixodes ricinus (wood-beetle), the last named being more 
common in Europe. In America wood-ticks are found in wooded 
districts, especially where pine- and fir-trees are growing. The fe- 
male occasionally attacks the human skin by thrusting into it her 
beak, armed on either side with a maxillo-labial projection having 
recurved hooklets, the mandibles also presenting similar obstacles to 
the forcible extraction of the head. After suction of the blood from 
beneath, the body of the tick swells to the size of that of a pea or small 
bean, and may remain for several days in this position. At such 
times the parasite may be mistaken for a small pedunculated tumor. 
Forcible attempts at extraction of the intruder are liable to detach 
the mandibles from the body, and thus leave them as the source of 
future irritation and even disagreeable inflammatory symptoms in 
the site of the punctured wound. On applying over the tick a drop 
of spirit of turpentine or benzine the head is spontaneously retracted 
and the body falls from its position. Soldiers on the plains of the 
United States accomplish the same end with the juice of tobacco. 
The sensation produced at the moment of the insertion of the beak of 
the insect is said to be so trifling as often to pass unnoticed. 

According to Modder, 1 the tick is responsible in some cases for 
the transmission of yaws. 

PEDICULOSIS. 

(Lat., pediculus, a little foot.) 

(Phtheiriasis, Morbus Pediculosis, Lousiness. Fr., Phthi- 
riase ; Maladie pediculaire ; Ger., Lausesucht. ) 

Lice belong to the order Rhynchota ; subdivision Parasitce; family 
Pediculidce. They are apterous, provided each with two eyes, and 
have an oral appendage capable of both inflicting wounds and pro- 
ducing suction. The lice infesting the human body are recognized 
as belonging to three varieties : those of the head, of the body, and of 
the pubes. Of the disorders to which they give rise, it may be said 
in general that the lesions presented differ according to the region 
invaded, to the multiplicity of the intruders, and to the length of time 
during which their ravages have been inflicted. Such lesions, how- 
ever are those which have been already studied in connection with 
eczema, urticaria, and the similar disorders resulting from external 
irritation. Their special peculiarities in pediculosis are owing solely 
to the nature of the exciting cause and to the mode of its operation. 

Evidence is accumulating that the louse, as well as the mosquito, 
the flea, and the bug, is capable of transmitting certain infectious 
1 Journ. of Trop. Med., etc., London, November 15, 1907. 



854 PARASITIC AFFECTIONS. 

diseases from man to man, if not also from the lower animals. 
Mackie, 1 studying the part played by pediculus corporis in the trans- 
mission of relapsing fever in one of the Bombay settlements, recog- 
nized that a much larger percentage of boys than of girls was attacked, 
the former having been found much more extensively infested with 
body-lice. In a well-marked percentage of observations, the lice were 
found to contain living and multiplying spirillar, the stomach being 
the chief seat of lodgment, the other organs of the parasites secon- 
darily invaded. After a careful dissection of the bodies of the lice, 
the author believes that the infectious secretion of the mouth is the 
medium of transmission. However tangled the masses of spirilla in 
the stomach, they were always found free in the mouth of the parasite. 

Pediculosis Capillitii. 

(Parasite, the Head-louse.) 

The head-louse (Fig. 178) is usually of a grayish color, but differs 
slightly with the hue of the hair on the part which it frequents. Its 
head presents indistinctly the outline of a trefoil, and is provided 
with two hairy antennae (each of five articulations) and with two 
eyes. Its thorax is relatively narrow, with six tracheal stigmata and 
three hairy legs on either side, the legs being provided with tarsal 
hooklets. The abdomen is divided into seven segments, defined by 
blackish indentations on either side. The males are fewer and 
smaller than the females, and they present upon the dorsum an ano- 
genital orifice and a large conoidal penis and testes. The females 
are provided with ovaries and with an anal aperture in the terminal 
abdominal segment. Coupling is performed with the male beneath. 

The ova or " nits " (Fig. 177) are whitish bodies of oval contour, 
that are glued to the hairs by a cylindriform sheath of chitin which 
completely encases each filament. They are deposited in series, as 
the female traverses the hair from its insertion to its distal extremity, 
so that the oldest are in general the nearest to the scalp. The young 
escape from the ova in from three to eight days, and arrive at ma- 
turity in from eighteen to twenty days. A single female, according 
to Kaposi, can lay fifty eggs in six days, and thus in eight weeks 
have a progeny of five thousand lice. 

Head-lice usually limit their habitat to the scalp, though, rarely, 
in elderly men with long hair reaching to a full beard, they may en- 
croach upon the latter. They infest every portion of the scalp, but 
find the region of the greatest protection upon the occiput. They are 
found upon children and adults of both sexes, but are furnished best 
with lodgement upon the scalps of girls and of women covered with 
long and luxuriant hair. The lesions observed upon a scalp thus in- 
habited vary according to the age and vigor of the colony. They are 
few or numerous, discrete or confluent pustules or bullae; the surfaces 
are excoriated by scratching, and ooze with serum, pus, or blood; 
1 Brit. Med. Jour., 1907, December 14, p. 1706. 



PEDICULOSIS CAPILLITII. 



855 



the crusts varying in character according to the nature of the desic- 
cated exudate and sebaceous matters. Often the picture presented is 
a conglomerate of an artificial eczema and seborrhoea. 

The ova, or " nits," are usually abundant upon the hairs of an 
infested head, and scarcely will escape the attention of a close ob- 
server. They are not to be mistaken for the exfoliated, epithelial, 
and fatty plates seen in seborrhoea sicca, disseminated among the 
hairs and often perforated by hairy filaments, since the former are 

Fig. 177. 



Fig. 178. 




Ova of head-louse at- 
tached to hair : 1, 2, 3, 
ova ; a, a, chitinous cylin- 
der surrounding a pilary 
filament ; b, chitinous 
sheath of nearly ma- 
ture ovum. (After Ka- 
posi.) 



Pediculus capillitii — male. 
(After Kuchenmeister.) 



glued firmly in position and resist the bristles of the hair-brush. The 
peculiarly nauseating odor of the louse-infested, pustule- and crust- 
covered scalp is not to be confounded with that due to favus of the 
same region. 

In aggravated cases the post-cervical ganglia express, by their in- 
crease in size, the degree to which the local irritation has been 
pushed. The itching is usually severe, and in cases of long persis- 
tence in children may produce the usual systemic symptoms of pro- 



856 PARASITIC AFFECTIONS. 

longed local irritation. Children and patients of impoverished health 
and with poor hygienic surroundings are believed to exhibit the dis- 
ease in severer grades than others ; but this, if indeed a fact, must at 
least in part be due rather to the more favorable conditions for de- 
velopment and multiplication of the parasites that are presented in 
filth-accumulation and lack of cleanliness. In the public charities 
of large cities children affected with pediculosis capillitii are pre- 
sented every week who come from the lowest social grades of the 
population and from the filthiest quarters. In these children it is 
not observed that the general health of the patients is a factor in the 
severity of the affection. 

Diagnosis. — The diagnosis of pediculosis capillitii is a matter of 
importance, however simple of accomplishment, since many cases of 
supposed " pustular eczema of the scalp " have vainly been treated by 
one physician with internal remedies addressed to the systemic vice 
supposed to be responsible for the disease which another has relieved 
after the discovery of a few head-lice. The hairs should always be 
raised and separated, the scalp carefully be inspected, and the pres- 
ence of any parasites, and especially ova or " nits " fastened to the 
hairs, be ascertained. Whether the lice have preceded or followed the 
eczematous state (and each of these conditions may be noted) is a 
matter of minor importance. Pustules about the nares and lips, espe- 
cially of young girls, are often significant of pediculi of the occipital 
region, the lesions being due to picking and scratching the face under 
an impulse to relieve pruritic sensations of the scalp induced by the 
presence there of lice. 

Treatment. — The indications in the treatment of pediculosis capil- 
litii are the destruction of all parasites with their ova, and the relief 
of the induced inflammatory condition of the scalp. Generally, re- 
moval of the former is followed by spontaneous disappearance of the 
latter. For the destruction of the lice the most popular remedy in 
the United States is petroleum (not kerosene), pure or with equal 
parts of balsam of Peru (which gives it an agreeable odor), poured 
over the scalp in quantity sufficient to cover it without overflow upon 
the brow, temples, and neck. It should be rubbed in with a piece of 
white (undyed) flannel. At the end of from twelve to twenty-four 
hours the lice are destroyed, and the ova are rendered incapable of 
development. This treatment is followed by a thorough shampoo with 
tincture of green soap, or with toilet-soap and hot water; after this 
operation the scalp may require a bland unguent, such as vaselin, or a 
small quantity of scented castor-oil, either pure or in combination 
with spirit of wine. Kaposi employs petroleum as a parasiticide in 
combination with olive-oil and balsam of Peru : 5 parts of the first, 
2/4 parts of the second, and 1 part of the third. Cutting the hair of 
women and children is unnecessary, as patience and gentleness with 
the use of the comb will disentangle the most matted masses after the 
lice have been destroyed. Other remedies are employed locally for a 
similar purpose, of which the most popular are staphysagria, 1 



PEDICULOSIS CORPORIS. 857 

drachm (4.) of the powdered seeds to the ounce (30.) of vaselin, 
but especially in decoction; tincture of cocculus indicus; carbolic 
acid in oil or water ; sabadilla ; the ethereal oils ; and mercurials in 
ointment and solution, including the mercuric oleates. In cases in 
which but a few parasites have found their way to the scalp, and that 
recently, nothing more is requisite than careful use of a fine-tooth 
comb, scrubbing the scalp with a strongly scented alcoholic perfume, 
and final bathing with soap and hot water. 

The ova adhering firmly to the hairs can be removed by soda or 
borax lotions, alcoholic solutions, or dilute acetic acid, which are sol- 
vents for the gluey material by which the " nits " are secured in place. 



Pediculosis Corporis. 

(Pediculosis Vestimenti, Phtheiriasis ; Parasite, the BODY- 
LOUSE.) 

The parasite in this disorder inhabits exclusively the clothing 
worn next the body. In anatomical peculiarities it resembles the 
pediculus capillitii already described, being, how- 
ever, larger in size, the females also larger than 
the males. The thorax is separated from the abdo- 
men, the latter being hairy, yellowish at the mar- 
gins, and provided with eight segments. The eyes 
are black and very prominent in both sexes; and 
the periods requisite for the maturing of the ova 
and young are those named respectively in connec- 
tion with head-lice. In color they vary from a 
dirty white to a light-grayish hue when undistended 
with blood. In the reverse of this last-named 
condition they may be recognized as having a 
dull-reddish or a purplish color, when they are 
also more indolent in their movements. They 
measure from 2 to 3 mm. in length and 1 to 1.5 Pedi cuius corporis— 
mm. in breadth. The female lays from seventy to kuchenmeisteb!) 
eighty eggs, from which the young are produced 
in from three to eight days, and are capable of reproduction in a 
fortnight more. 

They inhabit the seams of undergarments, where their ova are also 
deposited ; but in coarse woollen or flannel shirts they find sufficient 
shelter in the meshes of the material of which the clothing is made ; 
this they leave temporarily, solely for the purpose of obtaining nutri- 
ment from the skin of their host, and hence are not recognized upon 
the free surface of the integument. Upon rapid removal of the cloth- 
ing of an infested individual a few lice may occasionally be encoun- 
tered, hastily seeking a place of refuge, though this is rather the 
exception to the rule. It thus may happen that a louse-bitten patient 
will not exhibit the source of his trouble to his physician after a 




858 PARASITIC AFFECTIONS. 

recent and complete change of clothing. The greater then the im- 
portance of being able to recognize the clinical features of the malady 
in the absence of the parasite. This recognition is comparatively 
easy to one who has made himself familiar with the symptoms of the 
disorder. 

Swammerdam's original view that the louse is not provided with 
mandibles by which it can inflict a wound, but with a haustellum by 
which the blood is sucked up to the head of the parasite, is confirmed 
by Schjodte. The parts of the head resembling mandibles in appear- 
ance are really situated beneath its skin. A louse which previously 
had been starved, when applied to the skin retracted its limbs, arched 
its back, and inclined its head obliquely downward, as it projected for- 
ward and retracted a " small, dark, narrow organ," by which it was 
firmly held in place. A triangular blood-red point soon became visible 
in front of the eyes, rapidly and alternately contracting and dilating, 
and followed by energetic peristalsis of the gastro-intestinal tract. 
" If the head then be cut off in front of the eyes, and the haustellum 
carefully be extracted, the latter can be recognized as a brownish 
protrusion, armed with terminal recurved hooks, from which depends 
a delicate membranous tube varying in length. The mouth is like 
that in the rhyncota generally, out differs in the circumstance that 
the labium is capable of being retracted into the upper part of the 
head, and has a fold in it when so retracted. In order to strengthen 
this part, a flat band of chitin is placed on the under surface ; and it is 
thinner in the middle in order that it may bend and fold a little when 
the skin is not extended by the lower lip. The latter consists of two 
hard lateral pieces, of which the fore-ends are united by a membrane, 
so that they form a tube, of which the internal covering is a con- 
tinuation of the elastic membrane on the top of the head. Inside its 
orifice are a number of small hooks, which assume different positions 
according to the degree of the protrusion ; and if this be pushed to its 
highest point, they form a collar of hooks curved backward like barbs. 
The pediculns first inserts its labium into a sweat-pore and protrudes 
the lip. When the hook is securely attached to the parts around then 
the first pair of seta? (the real mandibles transformed) are protruded, 
and these are toward the point invested by a membrane so as to form 
a closed tube, from which again is exserted a second .pair of setse 
or maxilla 3 , which form a tube and end in four small lobes placed 
crosswise. The whole forms a membranous tube, along the walls of 
which retiform mandibles and maxillae are placed as long, narrow 
bands of chitin. This tube can be lengthened or shortened at 
pleasure." 

This explanation of the mode in which the louse attacks the skin 
is probably true of each of the varieties which infest the human body. 
The invaded follicle, after the withdrawal of the haustellum, becomes 
the seat of a circumscribed hemorrhage. None of the anatomical 
peculiarities described above, however, completely explains the char- 
acteristic pruritus of pediculosis corporis, for it can scarcely be ques- 



PEDICULOSIS COBPOBIS. 859 

tioned that it is not merely at the moment of attack or penetration 
that the suffering of the victim is greatest. The pruritic condition of 
the louse-wound persists, indeed usually attains its maximum, after 
withdrawal of the pediculus, and is without doubt greater than that 
awakened by merely mechanical puncture of the epidermis. 

The lesions seen on the skin thus invaded are proportioned, as in 
pediculosis capillitii, to the size and age of the colony of parasites. 
Excoriations, usually linear, occasionally circumscribed, varying in 
depth and length, radiate irregularly from each louse-wound, and they 
may be commingled with minute papules, transitory wheals, or, in 
rare, aggravated cases, with the typical signs of diffuse eczema. All 
are produced by scratching in order to relieve the pruritus. Crusts, 
often composed of desiccated blood, rarely of serum or pus, minute 
and capping the wounded follicle, or linear and coextensive with the 
excoriations produced by scratching, are generally conspicuous. In 
older cases these lesions are followed by the usual sequel, pigmenta- 
tion, the latter being a partial indication of lousiness which has 
long been tolerated. 

In America it is rare to note the severe and intense forms of the 
malady, resulting from long-continued neglect of the skin, that occur 
in Germany. In these cases follow: dermatitis, rupioid crusts, fur- 
uncles, abscesses, carbuncles, and ulcers, resulting in serious implica- 
tion of the skin which may persist for weeks after the clothing has 
been freed from lice, and finally leave a deep-tinted, diffuse pigmenta- 
tion of the skin-surface, suggesting that of the negro or of the patient 
affected with Addison's disease. 

Diagnosis. — The diagnosis is a matter of importance. Patients 
.will visit physicians, claiming that they have suffered from a "hu- 
mor of the blood," who have been swallowing drugs for a long period 
of time, in the vain hope of obtaining relief, with lice, at the very 
moment of uttering the complaint, crawling over their persons. 
Even those of good social position and cleanly habits will occasionally 
suffer after accidental contacts in the tram-car or railway-carriage, 
the hotel, the theatre, or other places of public resort. There are 
certain points to be carefully noted in this connection. Excoriations 
over the nucha, about the shoulders, loins, buttocks, and external faces 
of the thighs, all visible at the same time, are highly suspicious symp- 
toms ; as an eczema, when equally diffuse, is sure to be accompanied 
at some point by perfectly classical features ; and generalized pruritus 
is exceedingly rare, its localized varieties concerning chiefly the re- 
gions about the mucous outlets of the body. There is a picture highly 
suggestive of pediculosis exposed to the eye when the trunk of an in- 
fested patient is viewed from behind. The lesions are more dis- 
crete, more irregularly distributed and more intermingled with long 
scratch-marks, reaching, for example, quite over the point of one 
shoulder, than in most disorders with which pediculosis vestimenti 
could be confounded. Here and there minute blood-specks tell a sig- 
nificant tale. When clinical patients exhibit syphilodermata inter- 



860 PARASITIC AFFECTIONS. 

spersed among characteristic lesions of pediculosis corporis the stu- 
dents themselves in such cases can ordinarily point out the particular 
symptoms referable to the separate disorders present. 

In private practice it is usually advisable, for obvious reasons, to 
secure the corpus delicti before informing the sufferer of the nature 
of his or her complaint. In the case of male patients it is well to 
take a position in the rear, and when the underclothing is drawn well 
up from the shoulders a careful scrutiny of it may be made while the 
applicant for relief supposes that attention is directed instead to his 
person. 

Treatment. — The treatment of the disorder concerns largely the 
clothing. The latter requires immersion in boiling water, or it may 
be wrapped in paper and subjected to a temperature in an oven 
(160°-175° F.) sufficient to destroy the lice and their ova. In case 
of recurrence of the malady the clothing is to be again subjected to 
the same process. Usually the irritation of the skin resulting from 
the invasion promptly subsides. When several members of one fam- 
ily suffer, all clothing worn must be subjected to similar treatment. If 
the skin has been unusually tormented by scratching, warm alkaline 
baths will afford some comfort, and they may be followed by a bland 
unguent or by one of the dusting-powders. For immediate use, be- 
fore the clothing can be rid of the intruders, a small cheesecloth bag 
containing sulphur in stick or in powder may be worn beneath the un- 
derclothing, or the powder may be dusted in the clothing and rubbed 
over the body; or a parasiticide ointment may be ordered as recom- 
mended by Duhring, prepared by adding 2 drachms (8.) of freshly 
powdered staphysagria to the ounce (30.) of hot lard, strained and 
cooled. The surface of the skin may also be anointed with carbolic 
acid dissolved in oil or in water. 

Pediculosis Pubis. 

(Crab-louse. Parasite, the Pubic Louse. Fr., Morpion.) 

In this disorder the genital region is chiefly involved, though in 
exceptional cases all the hairy portions of the skin may be invaded, 
including the eyebrows, the eyelashes, the axillae, and the moustache 
and beard, the hairy chest, and the hairy legs of men. The body 
of the pubic louse (Fig. 180) is smaller than either of those de- 
scribed above. Its head is also attached more closely to its thorax, 
having a shape which is compared with that of a violin. The thorax 
is not distinctly separated from the abdomen, and of the six stout legs 
with which the louse is provided, the second and third pairs are 
conspicuously powerful and armed with relatively large hooks at the 
tarsal extremity. The resemblance of the latter to the claws of a 
crab has given to this creature the common name of " crab-louse." 
The lateral abdominal indentations are much less distinct than in 
the other varieties ; and the blackish marginal marks of body- and 
head-lice are here scarcely apparent. The abdomen is also much 



PEDICULOSIS PUBIS. SGI 

elongated, having a more rounded contour. The pubic louse is pro- 
vided on its lateral borders with eight short conical feet, terminating 
in bristles. It is also distinguished from the others of its family by 
the length of its anal bristles and by the peculiar shield-shaped cara- 
pace which covers nearly one-half of the dorsum. The male is from 
0.8 to 1 mm. long, and from 0.5 to 0.7 mm. wide, being thus from 
1 to 1.5 mm. smaller than the female. 

The pubic louse is much more inactive than the others, and does 
not ordinarily escape its pursuer. It buries its head deeply in a fol- 
licular orifice, and steadies itself in this position, where it may re- 
main for some time, by grasping the adjacent hairs with its short 
and powerful claws. A moderate degree of force is required for its 
dislodgment from this favorite posi- 
tion, and when removed its grasp of FlG - 18 °- 
the hair to which it clings is so firm 
that the latter usually slides for its 
entire length through the claw of the 
louse. Occasionally it may be found 
creeping over the skin or clinging to 
hairs at a distance from the skin-sur- 
face. The pyriform ova are smaller 
and fewer than those of the head 
louse, though having a similar color, 
and are, like the latter, attached to 
the hairs by a firm chitinous glue. 

Pubic lice are usually acquired 
during the contacts incidental to the Pedicuius pubis. (After schmaeda.) 
sexual act ; are, hence, more frequently 

encountered among adults ; but may, without question, be transmitted 
mediately by occupation of beds and clothing which have been used by 
infested persons. They are thus, though rarely, found in children 
of both sexes. 

The lesions induced are those produced by the wounds inflicted 
by the parasites and by constant scratching, though these are rarely 
severe. In a few cases a severe dermatitis follows the ravages of the 
lice, but in such event the complication is chiefly owing to unneces- 
sarily severe self-treatment of the disorder, patients being often mor- 
bidly anxious in their efforts to rid themselves of the pests. 

Diagnosis. — The diagnosis of pediculosis pubis is between eczema 
and pruritus genitalium. The disease last named is, in both sexes, 
accompanied by itching, and that often of intense grade; but when 
this is diffuse and symmetrical in distribution it is not limited par- 
ticularly to the hairy parts. Eczema of the genitals is not often pro- 
duced by parasites of that region, and it may readily be recognized 
by its characteristic features. Both disorders are often, indeed, 
limited to symmetrical patches upon the side of the scrotum or one 
labium. The discovery of the parasite, however, in pediculosis pubis 
is always essential, and requires merely careful inspection and a good 




862 PAEASITIC AFFECTIONS. 

light. The lice may be recognized either at or near the point of im- 
plantation of the hairs, which also display ova except in very recently 
infested individuals. The reddish excrement of the parasites mingled 
with scratch-marks and excoriated papules of small size may also he 
observed. Patients are often made aware of their condition by a sen- 
sation of crawling over the parts. Scratching of the pubic region in 
adults of both sexes should awaken suspicion of the disorder. 

Treatment. — The disorder is treated commonly by the topical ap- 
plication of mercurial ointment, which is a disagreeable and rather 
filthy medicament for this locality. The 10 per cent, oleate may be 
substituted for it, or, even preferably, corrosive sublimate in solution, 
from 3 to 4 grains (0.2-0.268) to the ounce (30.). Petroleum and 
olive-oil with balsam of Peru, in the proportions given above in con- 
nection with the subject of pediculosis capillitii, furnish an effective 
combination. Staphysagria, carbolic acid, cocculus indicus, or one 
of the other substances used in the disorders occasioned by the animal 
parasites, may be substituted if desired. It is usually better to defer 
bathing until the remedy selected for the destruction of the lice has 
been applied on several occasions, after which a warm water-and-soap 
ablution will commonly end the trouble. It is needless to clip the 
pubic hairs. Should a dermatitis follow, an appropriate treatment 
includes hot bathing and the blander lotions and unguents. 

Maculae Coerulese (Fr., T aches ombrees, T aches bleudtres) are pea- 
to small-coin-sized grayish stains found on the chest, belly, thighs, 
and upper arms, especially of blonde subjects. They have a steel-gray 
tint, do not disappear under pressure, and are believed to be, for the 
most part, signs of infestation with the pubic louse, though occurring 
in predisposed individuals independently of such invasion. Duguet, 1 
after inoculations with the juices of crushed pediculi, believes that 
he has demonstrated that the lesions spring from pigment originating 
in the body of the insect. 

Vagabonds' Disease.- — This is a term given to the condition of the 
skin recognized among tramps, inmates of poorhouses, and the filthy 
and neglected in general. The skin of such persons is often densely 
indurated, harsh, dry, and deeply pigmented, in consequence of much 
scratching and a consequent hyperemia. This condition is produced 
chiefly by phtheiriasis ; but is often a resultant of the incursions of 
several parasites, including those of the bed and of the clothing. It 
is also a consequence of persistent neglect of the bath. 
1 Annates, 1880, p. 544. 



CIMEX LECTULABIUS. 863 



CIMEX LECTULABIUS. 

(Bugs, Bedbugs, Acanthia Lectulakia. Fr., Pltnaise des Lits; 
Oer., Bettwanze. ) 

Strictly speaking, the bedbug is not a parasite of man, but finds 
its congenial habitat in the bed, bedding, and bed-covering, and the 
walls and floors of apartments occupied by persons of both sexes and 
all ages. It may find a host in certain of the lower animals such as 
the guinea pig. It infests also furniture, including chairs, sofas, 
and the cushions of seats occupied in public vehicles and hotels. 
From the cracks, crevices, seams, folds, or other protected points 
where it has found lodgment, it emerges usually at night, for the pur- 
pose of securing its nutriment in the blood of its victims. It is a 
pest as ancient as the day in which Dioscorides wrote. 

This insect has a rusty or reddish color, this differing slightly ac- 
cording as it is or is not distended with blood. It is an apterous 
member of the order Cimicidce. It is provided with a blunt-pointed 
head, broadly attached to the thorax ; two long, slender antennae ; and 
a three-jointed haustellum capable of projection and retraction be- 
neath the head. There are three pairs of long, slender legs by which 
it is enabled to accomplish rapid movements. The abdomen is broad 
and flattened, and oval in shape, with nine segments. The parasite 
emits a disgusting odor, which is much more distinct when it is 
' crushed. 

As the germs of anthrax have been recognized in the bodies of 
bed-bugs fed upon inoculated guinea pigs, 1 the possibility that these 
pests, like the mosquito, may become distributors of infectious dis- 
orders is great. They have been suspected as the media of transmis- 
sion of the plague ; and recently Goodhue 2 has stated that the bacillus 
leprse has been demonstrated in the bedbug. Mackie 3 has found spi- 
rillse of relapsing fever in the stomach of bedbugs. 

The wound inflicted by this bug is accomplished with or without 
the consciousness of its victim, who in the former case is made aware 
of a transitory prick or sting. Soon after, decidedly pruritic, burn- 
ing, or stinging sensations are experienced, and the wound becomes 
the seat of an urticarial wheal. The lesion then, examined soon after 
the infliction of the wound, is seen to be small pea- to bean-sized, and 
in the form of an elevated and circumscribed "button" or papulo- 
tubercle, either whitish in the centre or exhibiting there also the 
hypersemia which distinguishes its peripheral zone. After the lesion 
has begun to subside and lose its acute features, which may not occur 
for several hours if it be irritated by rubbing or scratching, a minute 
reddish punctum may be seen marking the original site of the wound. 

The lesions are usually multiple even when but a single assailant 

1 MeClintock, J. A. M. A., 1907, xlix., No. 23, p. 1933. 

2 "Mosquitoes and their Eelation to Leprosy in Hawaii," Amer. Med., 1907 
(New Series), ii., pp. 593-598. 
3 Lancet, 1907, September. 



864 PARASITIC AFFECTIONS. 

has been present, the insect taking apparent delight in obtaining its 
nutriment from several distinct points upon one surface. In this 
way at times its course upon the integument may for a short distance 
be traced. In cases in which the pests are numerous, as in filthy 
dwellings, prisons, ships, and barracks, and when infants have been 
attacked, the resulting eruption is often greatly masked by the scratch- 
ing and resulting excoriations of the skin-surface. In this way ves- 
icles, pustules, crusts, purpuric blotches, and even skin-infiltrations 
may be found, instead of the rosy or light-reddish typical wheals of 
recent cases in patients with fair, clean skins. 

Diagnosis. — The diagnosis is a matter of importance, and upon it 
may hang a professional reputation. Physicians are often consulted 
respecting these lesions by patients who believe themselves to be suffer- 
ing from " hives," " humors," exanthemata, and even from syphilis. 
The insect attacks the parts of the body to which access is easy as the 
patient sits or reclines on the back or side, including the buttocks, 
the thighs, the shoulders, the loins, and the neck, in that order of 
frequency, rather more largely than the legs, much less frequently the 
scalp, the face, and the genitalia. The eruption is not to be con- 
founded with urticaria ab ingestis. which is more apt to be symmet- 
rical in disposition. 

Treatment. — The eruption is best relieved by the topical appli- 
cation of spirit of camphor, alcohol, weak carbolated lotions, or solu- 
tions of boric acid, 1 drachm to the pint (5. to 500.). Untreated, it 
disappears spontaneously when the source of the disorder is removed. 
The most effective treatment is by prophylaxis, with soap, corrosive 
sublimate solutions in alcohol, and hot water employed over all 
accessories of the dwelling-house inhabited by the insects. Once 
discovered to be present, infested furniture should be scrubbed and all 
its crevices treated with a strong solution of corrosive sublimate in 
water and bed-clothing be immersed in boiling water. 

MOSQUITOES. 

The traumatisms of the skin produced by the mosquito have been 
invested with a striking significance as a result of recent bacterial 
investigation of the origin of several serious tropical affections. 

Non-pathogenic mosquitoes (gnats) constitute the larger of the 
chief classes of these insects; of the pathogenic class the more im- 
portant are the Anophelince, of which there are eighteen genera 
effective in the transmission of malarial fevers ; the Cidicidce, which 
transmit filarial disease ; and the Stegomyia fasciata, which has been 
demonstrated to be the medium of transmission of yellow fever. 
Goodhue (loc. cit. ) claims to have recognized the bacilli of lepra in the 
body of the female of Culex pungens. 

The impregnated female deposits her ova on the surface of stag- 
nant water where in from three days or more the larvae are hatched. 
After several moultings the pupa stage is reached ; later the insect 
emerges from the ruptured pupa-case and flies a few hundred feet to 



PBOTOZOA AND SPOEOZOA. 865 

seek its nutriment in mammals, fish, reptiles, or other insects. The 
female mosquito alone is the germ carrier. Much of the advance 
made in tropical countries in the direction of elimination of endemic 
disorders has been brought about by scientific destruction of the ova 
or larva? of these insects before they arrive at maturity. 

The bodies of immigrants newly arrived during the summer sea- 
son in America, from countries where the mosquito is either rare or 
does not exist, often present singular and even formidable evidences 
of the attacks of these insects. The skin, unaccustomed to such 
depredations and quite unprotected, will often be found greatly swol- 
len, and of a light-reddish hue suggestive of erysipelas. Here and 
there bulla? are conspicuous, which add to the resemblance to the 
last-named disease. The features, in consequence of the tumefaction, 
vesiculation, and papulation, may be so swollen as to present a con- 
spicuous deformity; and the forearms, and even the arms, seem 
greatly increased in size from the same cause. The feet and legs 
also may, in the unconsciousness of sleep, be exposed in hot weather 
to the depredations of these marauders, and in the same way the 
back, the buttocks, and, rarely, even the genitalia may present the 
same signs of inflammation. The matter of chief moment is the cor- 
rect diagnosis of such cases, as many patients seeking relief under 
such circumstances have been treated for disorders with which they 
were not affected. 

Other insects may persistently or occasionally attack the human 
skin; midges (Simulia) ; bees (Apes melliferce) ; and wasps (Ves- 
pidce). They produce by their bites or stings various cutaneous le- 
sions, including urticarial wheals, papules, ecchymoses, and in. rare 
cases even ecchymomata. The lesions produced by the midge, like 
those of the mosquito, are seen on the face, the hands, and exposed 
parts ; though, when numerous and voracious, these insects will pene- 
trate the clothing for the purpose of obtaining blood. Severe erup- 
tive lesions are often seen in America on the faces and extremities of 
infants and children exposed during the night to the incursions of 
these marauders. The skin-symptoms may be treated locally by aqua 
ammoniae or spirit of camphor. 

PROTOZOA AND SPOROZOA. 

The relations sustained by some forms of protozoa to diseases of 
the skin and of other organs in man are as yet undetermined. The 
so-called psorosperms observed by a number of investigators in 
Darier's disease, carcinoma, molluscum fibrosum, Paget's disease, 
herpes zoster, and varicella have been demonstrated clearly to be 
bodies produced by cell-transformation. 1 It is well known, however, 

1 Cf. Gilchrist, Johns Hopkins Hospital Reports, i., 1896 ; and Second Annual 
Report of the Cancer Committee of the Harvard Medical School, Journ. Med. 
Resch., 1902, vii., No. 3. 

55 



866 PAEASITIC AFFECTIONS. 

that the livers and other organs of rabbits and of some other animals 
often contain coccidise (a subclass of sporozoa), and several instances 
of peculiar forms of disease in man have been reported in which 
protozoa were satisfactorily demonstrated. Psorospermosis of in- 
ternal organs of man is described by Osier 1 and by Blanchard. 2 

Protozoan and coccidoidal infections of the skin are considered 
with cutaneous blastomycosis. 

1 Principles and Practice of Medicine, p. 1080, p. 682. New York, 1895. 
2 Bouchard's Traite de Pathologie generale, tome ii., p. 682. Paris, 1896. 



CLASS IX. 
DISORDEES OF THE APPENDAGES. 



In this class of disorders are grouped the functional affections of 
the sweat-glands, or coil-glands, the sweat-pores, and the sebaceous 
glands. These disorders may be betrayed in quantitative or in quali- 
tative changes in the secretion, or in retention of the latter in the 
whole or in a part of the secretory apparatus. When a disease of the 
skin ceases to be purely functional in type, and is accompanied by an 
exudative process, glandular or periglandular in situation, such dis- 
ease is properly classed with another group of affections. With a 
view, however, to convenience of arrangement there have been placed 
in this class a few dermatoses which cannot be regarded as strictly 
functional affections. 

SWEAT-GLANDS. 1 

HYPERIDROSIS. 

(Gr., virep, in excess; vSup, water.) 

(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, Hyper- 
hidrosis. Fr. } Hyperidrose. ) 

Hyperidrosis is an exaggerated quantitative effusion of sweat, 
localized or generalized, moderate or severe, acute or chronic, persis- 
tent or relapsing, the secretion accumulating in visible drops upon 
the surface of the skin. 

Symptoms. — This condition may be physiological, as the result 
of active exertion in a medium of high temperature; or it may be 
pathological in character, and in the latter case be either general or 
partial. 

The expression, general sweating, is self-explanatory. The entire 
skin of the body participates in the process, and the surface conditions 
which result favor the development of intertrigo, sudamina, miliaria, 
and occasionally of folliculitis and furunculosis. Local hyperidrosis 
is the exaggerated quantitative effusion of sweat limited to certain 
definite portions of the skin, as the palms, the soles, the dorsa of the 
hands and feet, the interdigital spaces, the genitals, the axillae, and 
the temples. In such cases the secretion occurs moderately or greatly 
in excess, varying in this respect somewhat in different degrees of 

1 Excellent bibliographies relating to the various disorders of the sweat-glands 
may be found in Torok's contribution to the subject in Mracek's Handbuch, Bd. 1, 
pp. 386-485. 

867 



868 DISORDERS OF TEE APPENDAGES. 

temperature and in rapidity of the circulation. It may involve one 
or both sides of the body, being generally symmetrical upon the 
extremities and asymmetrical upon portions of the face. 

The typical expression of this disorder may be studied in the 
hands, which are continually moistened, clammy, or dripping with 
fluid within a brief time after the most careful drying of the parts. 
The sweat is commonly cold to the touch of another. In the case of a 
woman, the instincts of whose sex prompt her to take such precau- 
tions, the dress is constantly protected from contact with the macer- 
ated palms by a handkerchief or similar article which is always in 
readiness, and frequently no small complaint is made, of the dis- 
agreeable results produced after wearing kid gloves for even a 
short time, the material of which is soon soiled by its complete satura- 
tion with the secretion from the skin. The disadvantages thus aris- 
ing in individuals of both sexes who are engaged as tradespeople, 
artists, hand-workers, etc., are obvious. The skin on the palmar sur- 
face of the hand, and often on the dorsal aspects of the fingers has a 
sodden, thickened appearance, and some degree of hyperkeratosis is 
always present in severe cases. Occasionally vesicles are formed 
which later become centres of slight exfoliation. 

With and without this local excess of perspiration involving the 
hands, occurs the hyperidrosis of the feet. The outpour of sweat 
varies in amount from a mere dampening of the feet to a complete 
saturation of the stockings and the leather of the boots or shoes with 
the secretion. There is usually a very offensive odor of the region, 
originating partly in the primary fetor of the secretions themselves, 
and partly in the subsequent chemical decomposition of the latter, 
rapidly progressing under the influence of the soiled and often stink- 
ing investments of the feet. The integument, constantly macerated, 
may become both painful and tender and slightly reddened ; occasion- 
ally there is vesiculation or exfoliation of patches of sodden epidermis, 
especially between and beneath the toes, in which situation fissures 
are prone to occur. As upon the hands, though to an even greater 
degree, an hyperkeratosis is found, which may be regarded as an effort 
of the organism to compensate for the effect of constant maceration. 
The nails are usually thickened and distorted, the result of participa- 
tion in the keratotic process. 

Hyperidrosis of the axillary and genital regions is very often at- 
tended with more or less bromidrosis and almost invariably leads to 
some degree of intertrigous irritation. The wearing of impervious 
shields by women to protect the dress waist from unsightly staining 
favors the retention and decomposition of the secretion, and thereby 
adds to the macerating and irritating effects upon the skin of the 
part. Itching is a frequent complication, and folliculitis, and furun- 
culosis, or a dermatitis seborrhoica may supervene. Excess of sweat 
in the inguinal and genito-crural regions, because of the peculiarities 
of the location, is especially apt to decompose. More or less fetor 
results, and if the individual is inclined to obesity a troublesome 
intertrigo or follicular dermatitis may develop. 



HYPERIDBOSIS. 869 

Etiology. — General sweating to a pathological extent occurs in the 
obese and in those who are subjects of systemic disease, notably tuber- 
culosis, acute rheumatism, malaria, rickets, exophthalmic goitre, and 
various febrile disturbances. It may result from adynamia due to 
any cause. Both local and general hyperidrosis has been observed in 
organic diseases of the nervous system, such as general paralysis 1 and 
myelitis. Traumatisms, gliomata, gummata, scleroses, and other 
lesions affecting the cerebrum, medulla, cord, ganglia, and nerve 
trunks have all been followed by hyperidrosis of the entire body or of 
a part only. It is extremely common in persons with an habitually 
rapid heart, and in those who use too freely the narcotico-stimulants, 
such as alcohol, tobacco, coffee, and tea. 

The frequent obscurity of etiologic relations in hyperidrosis is 
entirely explicable when certain facts are considered. The predomi- 
nant influence of the nervous system must be admitted. Though but 
indefinitely located, the existence of special centres and fibres in the 
central nervous system for the control and operation of the sweat- 
glands is evidenced by a mass of clinical observation. The relation 
of the sympathetic nervous system to all glandular activity is well 
known. The positive results of experimentation and the deductions 
warranted by clinical experience indicate that irritation of those 
centres and fibres, either central or sympathetic, which are secreto- 
motor, or paralysis of those which are secreto-inhibitory, accounts for 
general or local hyperidrosis according to the extent of the distribu- 
tion of the nervous elements concerned. The etiologic complexity of 
the situation arises from the fact that this stimulation or paralysis 
may follow numberless causes ; emotion, action of circulating toxines, 
direct injury, pressure effects, reflex action from the periphery or 
from within, etc. The efforts of the clinician in accumulating data 
must be supplemented further by those of the anatomist and physi- 
ologist before the etiology of hyperidrosis is completely worked out. 

Pathology. — Robinson, who examined a number of sections from 
the palm of the hand, failed to detect any abnormal feature either in 
the glands or in the epithelium. The disorder is to be regarded as 
purely functional ; and any anatomical changes in the coil-glands or 
the sweat-pores are probably accidents of such derangement of 
function. 

Treatment. — When universal, hyperidrosis is to be treated inter- 
nally by the aid of such remedies as are indicated by the general 
condition of the patient, and especially by the condition of the heart. 
The various ferruginous tonics, mineral acids, arsenic, strychnine, 
strophanthus, quinine (the latter particularly when, as is often the 
case, a malarial affection is responsible for the disorder), and ergot, 
with both belladonna and atropine, are all of unquestioned value. 
Crocker administers sulphur internally. Even though but temp- 
orarily serviceable, belladonna and atropine are well used at the out- 
set of most cases. Aconite, jaborandi and pilocarpine, white agaric 
1 Cf. Be Montzel, La Presse Med., 1903, January 31. 



870 DISOEDEES OF THE APPENDAGES. 

(agaricin is recommended in doses of % grain (0.011), repeated as 
required), carbolic and salicylic acids may be named as in the second 
rank. The narcotico-stimulants as a rule should be excluded. 

External treatment, which is often promptly efficacious, should 
not be neglected in any case. The simplest method is by wiping, not 
washing, the skin-surface until it is dry, and applying a dusting- 
powder, such as lycopodium, talc, salicylic acid, boric acid, bismuth, 
magnesia, chloral hydrate (1 part to 5 or 6 of starch), or starch. Al- 
ternately with either of these, or in lieu of them, baths or lotions may 
be employed, aqueous or alcoholic, and medicated with corrosive subli- 
mate, formalin (1 to 5 per cent, solution), tannic acid, ferrous sul- 
phate, naphtol (Kaposi), turpentine, zinc sulphate, alum, potassium 
permanganate, or common salt. Daily sponging of the affected sur- 
face with weak solutions of formalin (1 to 6 per cent.) will remove 
the odor, and will in most cases greatly diminish the amount of 
perspiration, but on suspension of the treatment the condition usu- 
ally returns. Fox 1 advises a lotion containing 1 part of quinine to 
100 of alcohol. Van Harlingen recommends the use of juniper-tar 
or carbolic acid soap with the bath as alone sufficient to relieve some 
cases. Grosse 2 praises highly tannoform, either in powder (1 part 
to 2 of talcum) or as a 25 per cent, plaster. 

For hyperidrosis of the feet the treatment by the method of 
Hebra has deservedly high repute. It consists in neatly and com- 
pletely enveloping the entire foot, the toes separately, after thorough 
washing and drying, in strips of cotton-cloth over which is spread to 
the thickness of a common knife-blade the unguentum diachyli albi. 
This unguent is made by boiling 1 part of the best litharge with 
about 4 parts of pure olive-oil, to which a little water is added while 
the materials are stirred together over a slow fire. The parts are 
well bandaged, and the patient either remains subsequently at rest or 
pursues his vocation, wearing over the feet shoes and stockings which 
have not previously been worn. In twenty-four hours the feet are 
redressed without washing, after dry rubbing with charpie and a dust- 
ing-powder. This treatment is repeated daily for from ten to twenty 
days, after which a dusting-powder (boric acid) may be substituted 
for the local dressing. . There occurs a parchment-like desquamation 
of the epidermis in thick, yellowish-brown lamellse, beneath which is 
formed a new and at first tender but apparently normal epidermis. 
When the latter has lost its tenderness the feet are for the first time 
washed with water. In case of failure the routine of treatment is 
repeated as often as requisite. It is scarcely necessary to add that no 
ill effects are known to have resulted from the therapeutic measures 
adopted in checking a local hyperidrosis. For the diachylon salve 
there may be substituted tar, ichthyol, or naphtol ointment. 

Gerdeck 3 makes three applications to the soles, at intervals of 

1 J. C. D., 1885, iii., p. 24. 

2 Klin, therap. Wchnschrft., 1889, Nos. 16 and 17. 

3 La Kiforma Medica, 1898, No. 38. 



SUDAMEN. 871 

about eight hours, of the strongest solutions of formalin the skin of 
the individual will bear. In some instances full strength is well tol- 
erated. A few drops are put in the shoes, the influence on the leather 
being preservative and not destructive. Eelief follows for several 
weeks, when the treatment may be repeated. 

Frederick employs finely pulverized tartaric acid, applied at first 
with some caution, and always in small quantities. Stewart first 
bathes the feet in hot water and then soaks them for a few moments, 
once only, in a solution of potassium permanganate, 4 to 6 grains to 
the ounce (0.266-0.4 to 32.), after which the plaster selected for use 
may be applied as directed above. Legoux orders pediluvia of tar- 
water twice daily for three days, followed by painting of the feet with 
a solution of iron perchloride. Morrow 1 recommends foot-baths in 
the extract of pinus Canadensis, followed by the application of boric 
acid, or of salicylic acid mixed with lycopodium. The use of the x- 
ray has been very effective in cases treated by us. In axillary 
hyperidrosis we have found it useful pushed to the point of producing 
a slight reaction. 

Prognosis. — The future of any case of hyperidrosis is uncertain. 
The disease, whether local or general, may spontaneously disappear, 
may recur, may promptly be amenable to treatment, or may prove 
obstinate to all therapy. Myrtle 2 reports the case of a male patient, 
seventy-seven years old, who sweated to death after repeated recur- 
rences of severe hyperidrosis, and after temporary relief from the use 
of Fowler's solution. As regards these reported fatal cases it must 
be said that it is extremely doubtful whether hyperidrosis per se has 
ever caused death. 

SUDAMEN. 

(Lat., sudor, sweat.) 
(Miliaria Crystallieta. Ger., Friesel ; Fr., Miliaire 

CRYSTALLINE.) 

Symptoms. — In this disorder the lesions are thickly agglomer- 
ated, but discrete, transitory, and translucent, pin-point-sized vesicles, 
resembling dew-drops or seed-pearls, upon the surface of the skin, 
often requiring the touch to define their real character. These lesions 
are usually limited to certain regions of the body, as the neck, chest, 
or other parts of the trunk, but rather more generally develop upon 
the front and sides of the belly and in the iliac regions, though they 
may occur upon any part. They contain each a droplet of sweat, 
which is removed by evaporation. Their course is rapid, both in evo- 
lution and involution, and their sequelae are exceedingly delicate des- 
quamative flakes, the thin roof-wall, which originally covered the 
sweat-drops, having been lifted from the superficial stratum of the 
horny layer of the epidermis. They are usually preceded by an at- 
tack of pruritus. 

1 See his resume of this subject in J. C. D., 1887, v., pp. 68, 113. 
3 Medical Press, February 25, 1886. 



872 DISORDERS OF THE APPENDAGES. 

Three forms of sudamina have been described : (a) sudamina 
alba; (b) sudamina rubra; and (c) sudamina crystallina. The last 
named is the only form to which the term sudamen is properly ap- 
plied, since it alone of the three designates a purely functional de- 
rangement of the sweat-secreting apparatus. 

The first term, sudamina alba (miliaria alba), is applied to the 
lesions occurring where there is maceration of the vesicular wall and 
when the contents become opalescent. This form is rare. The sec- 
ond term, sudamina rubra (miliaria rubra, miliaria papulosa, lichen 
tropicus, "prickly heat"), is applied to inflammatory lesions which 
may accompany profuse sweating. These lesions are numerous, acu- 
minate, pin-point- to pin-head-sized vesicles surrounded by a reddish 
halo, or papules of the same dimensions, or the two lesions commin- 
gled, almost invariably accompanied by hyperidrosis, though the latter 
may be absent in high temperatures. Areas of diffuse redness may 
develop where few of the elements of the eruption are visible. The 
marked tingling, pricking, and burning sensations by which they are 
accompanied are often in the highest degree distressing, and may so- 
licit rubbing of the affected part, though the scratching elicited by 
severe pruritus is not common. Minute crusts may form after vesic- 
ular rupture. The attack may be mild or severe, and may last for 
a few days or for a few weeks or months, the result of continuous 
aggravation or of the production of new crops of lesions after each 
recurrence of the cause. The affection is not rarely complicated in 
obese individuals by all varieties of intertrigo and eczema. Suda- 
mina crystallina are, however, the sole lesions which may properly 
be referred to this class of affections. These vesicles are always 
free from inflammatory symptoms, presenting a limpid, dewdrop-like 
aspect that is characteristic. 

Etiology. — The disease is the result of excessive sweating, induced 
by any cause, as violent exercise, the elevated temperature of the sum- 
mer season, flannel underclothing, vapor baths, or hot fomentations 
applied to the skin. It not infrequently follows the hyperidrosis of 
systemic debility, tuberculosis, inflammatory rheumatism, and the 
acute infectious fevers. The vesicles may occur as symptoms of the 
death-agony. 

Pathology. — Robinson reports that the contents of the vesicles are 
pure sweat without admixture of lymphoid corpuscles. The fluid col- 
lects between the laminae of the deeper part of the corneous layer. A 
rupture of the wall of the sweat-duct may occur, but there may be 
instead obliteration merely of the sweat-pore by a sudden effusion of 
watery fluids toward the epidermis, that pass with moderate pres- 
sure through the wall-less sides of the pore into the spaces between the 
epithelial cells, where a chamber is readily formed. Torok 1 found 
the walls of the vesicle composed purely of the corneous layer with 
a sweat-pore opening at the lower border of the chamber. 

Diagnosis. — iSTo difficulty can arise in making a diagnosis if the 
a Mracek's Handbuch, Bd. i., pp. 418-422 (with bibliography). 



MILIARY FEVER. 873 

peculiar characters of the sudamen be kept in view. All pustular 
lesions have different contents; all bullous lesions are larger, or are 
seated on an engorged base, or they lack the limpid clearness of 
the sudamen, because, however transparent the contents, they are 
mo'stly covered by a thicker and less transparent roof. The halo 
about the lesions of milaria rubra, or their rosy-pink shade, will de- 
termine their character. In varicella the lesions are chambered. 

Treatment. — Only the simplest treatment is required. Alkaline 
and bran baths may be employed, of the temperature most grateful to 
the skin. Afterward the surface may be dusted with one or several 
of the dusting powders, such as starch, lycopodium, or boric acid, 
named in the Chapter on General Therapeutics. The internal treat- 
ment is that indicated by the condition of the patient. 

Strophulus ("Red Gum") is a term still employed by a few Eng- 
lish writers to designate an eruption due to excessive sweating in the 
infant closely swaddled. Crocker states that it occurs frequently as 
a unilateral affection of the side most in contact with the mother's 
body. 

MILIARY FEVER. 

("Sweating Sickness"; Fr., Suette miliaire.) 

This is an epidemic disorder, accompanied by sweating and a cu- 
taneous exanthem. Pineau 1 gives a description of the disease as it 
occurred in epidemic form on the island of Oleron, where of one 
thousand patients affected, between one hundred and fifty and two 
hundred perished. The eruption appeared in the form of hyperaemic 
maculae, disappearing under pressure, after which there rapidly 
formed myriads of reddish or whitish, grouped, unequally sized, acu- 
minate papules rising from a whitish and macerated surface. Among 
these papules were interspersed lesions of sudamina. The region of 
the face was not spared, and the conjunctivae were occasionally af- 
fected. In the course of from two to four days pinhead- to bean- 
sized, varioliform but non-umbilicated pustules formed in the site 
of some of the papules, the contents of which disappeared by resorp- 
tion, the final lesions presented being large, flat, reddish papules, the 
skin of the face particularly becoming reddened and swollen. In 
the course of from ten to twelve days general desquamation ensued, 
with extensive palmar and plantar losses. Relapses occurred in some 
cases with diffuse redness of the surface or with crops of reddish 
plaques, or yet again with the occurrence of furuncles. The sensa- 
tions were those of myriads of needles thrust into the skin. 

The exanthem was accompanied in some cases by fever. In the 
fatal cases death resulted from exhaustion. 

Geber and other writers, however, believe that the lesions de- 
scribed are not peculiar to any special disease, and they deny the 
possibility of an independent miliary fever. 

1 Arch. gen. de med., Jan., 1882, p. 25. 



874 DISOEDEES OF THE APPENDAGES. 

HYDROCYSTOMA. 

(HlDROCYSTOMA, CySTS OF THE CoiL-DUCT.) 

Hydrocystoma is a chronic non-inflammatory disorder character- 
ized by the presence on the face of scattered, isolated, deep-seated, 
persistent, clear vesicles. Robinson 1 has published a report of his 
studies in this affection, which he first described in 1882. Reports 
of cases and studies of the disease have been made also by Hutchinson, 
Jackson, Jamieson, Rosenthal, Hallopeau, Tebel, 2 and others. 

Symptoms.— The lesions are discrete or closely set, few or exceed- 
ingly numerous, tense, well-developed, clear, shining, rounded or oval, 
pin-head- to pea-sized vesicles, non-inflammatory, and never super- 
ficially seated — that is, never so near to the surface as the vesicles of 
miliaria — because the base of all hydrocystomata is to be found in 
the corium. They have no tendency to rupture spontaneously. The 
lesions are whitish in color, or when of greater age and size are dark 
bluish, especially at the periphery, some resembling boiled sago-grains. 
The signs of inflammation are absent ; occasionally a mild hyperemia 
becomes evident at the periphery of a single cyst. The contents are 
neutral or slightly acid in reaction, and pellucid, never changing to a 
yellowish hue, and when uninjured resolve in time by desiccation, 
leaving a short-lived pigmentation. They occur chiefly upon the 
face, especially the brow, cheeks, and nose, in symmetrical distribu- 
tion, and may prevail for weeks or months, or disappear in cool 
weather. They are always accompanied by very free sweating. 

Etiology. — -The disease occurs almost invariably in middle-aged 
women, more often in those engaged as laundresses who have been 
sweating freely at their work, the face being simultaneously exposed 
to warm vapor. Men are very rarely affected. There is usually 
aggravation of the disorder in summer and either complete or par- 
tial relief in winter. Aggravation has been noted at the time of the 
menstrual period. One of Hutchinson's patients exhibited lesions on 
a single side of the face only. The patients seen by us have been usu- 
ally of the dispensary class, and were women who worked much over 
the wash-tub. Hyde and McEwen 3 have reported a typical case oc- 
curring in a woman past the menopause, where sweating was one of 
the symptoms of exophthalmic goitre. Inasmuch as the histology of 
the disorder demonstrated the necessity of a closing of the peripheral 
portion of the sweat-duct for the development of typical lesions, any 
factor which would lead to such closure, as by pressure about the ex- 
cretory duct, must be reckoned as etiologic. Among these conditions 
may be mentioned scarring processes such as lupus vulgaris, favus, and 
variola; inflammatory disorders such as acne and rosacea, etc. In 
fact as the sweat-pore can be obstructed in many ways, the etiology 
of hydrocystoma must be regarded as complex, though seemingly 
simple. 

1 J. C. D., 1893, xi., p. 293. 

2 Annales. 1903, s. iv., iv., p. 273. 

3 Amer. Jour. Med. Sci., June, 1903, n. s., cxxv., p. 1000. 



HYDBOCY STOMA. 875 

Pathology.. — The epidermis, hair-sacs, and sebaceous glands are 
in all parts normal, the papillary layers being involved only when the 
cyst approaches the upper part of the corium, where " a thin plate 
of flattened papillary body" is found above. Below, in places, the 
lumen of the sweat-duct is found enlarged and distended with liquid 
and a granular material. The enlargement in the duct begins above 
the coil of the gland, and usually in the lower part of the corium. 




Hydroeystoma. (Howard Fox.) 

There is some perivascular leucocytosis in progress here and there in 
the vicinity of the vessels, but this was not a marked feature in any 
one of the several sections examined by Kobinson. The cavities of 
each duct were found lined with epithelial cells. Adam 1 believed the 
cyst to develop in the coil portion of the gland, but the finding of Rob- 
inson, that the duct immediately above the gland proper is the part 
involved, has been confirmed by the researches of several authorities. 2 
Diagnosis. — The lesions of sudamen and pompholyx are readily 

1 B. J. D., 1895, vii., p. 169. 

2 Cf. Jarish, Hautkrankheiten, Wien, 1908; Lebel, Annales, 1903, s. iv., iv., p. 
273; Pinkus, Derm. Zeitschr., 1904, xi., p. 642; Schidaehi, Arehiv, 1905, lxxxiii., 
p. 3 (experimental production of hydroeystoma) ; Torok, Mracek's Handbuch, 
Bd. i., pp., 423-426 (with excellent bibliography) . 



876 DISOEDERS OF THE APPENDAGES. 

distinguished by their superficial character and their situation, as 
they are rarely discovered upon the face. The vesicles of eczema are 
short lived and inflammatory. In adenoma of the sweat-glands the 
lesions are often painful and usually firmer and larger than in hy- 
drocystoma. 

Treatment. — The lesions can be caused to disappear by punctur- 
ing each, thus permitting the escape of the imprisoned fluid. A weak 
spirit lotion may then be applied, and this may be followed by the 
application of dusting-powders, due care being had to avoid the effec- 
tive causes of the malady. 

ANIDROSIS. 

(Gr., a, privative; pvSu, water.) 

(Anhidrosis. Ger. and Fr., Anhidrose.) 

This name is applied to those morbid conditions in which no 
sweat is secreted from the surface of the body. Hypohidrosis and 
oligidrosis are terms more exactly used to designate a relative, gen- 
eral, or partial decrease in the quantity of the sudoral fluid. Ani- 
drosis, however, often is used to indicate the latter. 

Diminution in the quantity of sweat excreted, or its complete sup- 
pression, whether general or local, may be a congenital or acquired 
peculiarity of the individual, or may be a symptom of several dis- 
orders, but as an idiopathic cutaneous affection it is rare. It occurs 
in ichthyosis, atrophy, and in those conditions in which destructive 
changes have taken place in the skin. It is common to many derma- 
toses, as, for example, psoriasis, erysipelas, and some forms of ec- 
zema ; but in these the symptomatic character of the anomaly is 
shown by the fact that when the skin is relieved of these cutaneous 
troubles the function of sweat-secretion is restored. Similarly in 
neuralgias and certain forms of paralysis a circumscribed and tem- 
porary anidrosis may be the local expression of the nervous disturb- 
ance, precisely as in the case of the symmetrical hyperidroses. Ani- 
drosis has been observed in association with chronic nephritis; in 
such relationship it is probably causal to some degree. ISTot infre- 
quently individuals who do not sweat are prone to display upon the 
skin manifestations of an erythematous or urticarial type. 

Treatment. — The measures capable of stimulating the sweat-se- 
cretion are : ingestion of water in quantity by the mouth, the external 
application of heat in a dry or moist atmosphere, and the use of 
jaborandi or pilocarpine by the mouth or by hypodermatic injection. 
In the anidrosis accompanying cutaneous disease the indication is 
always primarily for the relief of the latter. 



BROMIDBOSIS. 877 

BROMIDROSIS. 

(Gr., flpufioc, a stench; vSup, water.) 

(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat. Gar., 
Stinkender Schweiss; Fr., Bromidrose.) 

Symptoms. — In bromidrosis 1 the perspiration is effused in such a 
state that immediately it can be perceived to possess an unusual odor, 
or, as Hebra taught was the case with the majority of patients, to be 
rapidly changed to that condition. It is often associated with hyperi- 
drosis, but may occur independently of the latter, and like the latter 
also be either general or localized. The odor may be either agreeable 
or disagreeable, having been in various cases compared to that of 
certain flowers and fruits as well as to that of several stench-emitting 
animals. In this respect the sweat presents a striking analogy to the 
urine, with which it sustains a close and well recognized physiological 
relation. 

General bromidrosis may be physiological, as in the case of indi- 
viduals of the African race, or in those with dark skins who are pro- 
fusely sweating during labor or in high temperatures. General path- 
ological bromidrosis is rare. The odors emanating from the person in 
ulcerating syphilodermata, small-pox, malignant pemphigus, mycosis 
fungoides, and other disorders may, in certain cases, be associated 
with the sweat-secretion, but in other cases they doubtless are con- 
nected with the decomposition of pathological products of the inflam- 
matory process. 

The local varieties of bromidrosis affect the regions in which the 
sweat is oftenest secreted in excess and its immediate evaporation 
prevented, as in the axilla, the groins, the feet, the ano-genital, and 
the intermammary and inframammary regions. In a qualitative 
sense every degree of odorousness is noted, from that which is merely 
slightly disagreeable or offensive to the most intolerable stench. 
When complicated by a seborrhoea, in situations where the parts are 
not only warm, moist, and covered by clothing, but also subject to 
friction and remaining uncleansed, the most intolerable and nauseous 
fetor is perceived. As in hyperidrosis, there may be coincident or re- 
sulting redness, swelling, and even vesiculation or superficial inflam- 
mation of the region where the symptoms chiefly are declared. 

Etiology and Pathology. — The use of strongly smelling drugs 
such as valerian, asafcetida, musk, etc., has been known to produce 
odorous perspiration; a similar observation can be made regarding 
certain foods (onions, garlic) and drinks. It is occasionally due to 
emotional causes, 2 to chronic alcoholism, or to the gouty state. Sys- 
temic diseases, such as diabetes, Asiatic cholera, typhoid fever, ty- 
phus, dysentery, scurvy, septicaemia, and pyaemia, may impart pe- 
culiar odors to the perspiration. Neurasthenia and dietetic errors 

1 Cf. Monin, ' ' Sur les Odeurs du Corps Humain, ' ' Ann. d. I. Soc. de Med. 
d'Anvers, Paris, 1885. Abstr. J. C. D. T 1885, iv., p. 211. 

2 Cf. Hammond, 1ST. Y. Med. Eec, 1877, xii., p. 460. 



878 DISORDERS OF TEE APPENDAGES. 

(meat-eating in excess, alcoholism, etc.) may be responsible for the 
affection at almost every age and in individuals of either sex. In a 
mild form it is common in vigorous brunette women soon after the 
puberal epoch and during menstruation. In bromidrosis of the feet 
Thin 1 has recognized micro-organisms (Bacterium fcetidum) in sweat 
obtained ; Parkes concludes that the only cause of the disease is the 
covering of the foot, as soldiers with uncovered feet do not suffer 
from this affection. The fact is patent to every observer that sweat 
may be effused in a normal condition upon and within the articles of 
clothing worn, and subsequently generate a stench by chemical 
changes both in the clothing and the fluid by which that clothing is 
saturated. 

Treatment. — The treatment of bromidrosis is in general that of 
hyperidrosis, already described. Internally sodium salicylate has 
been employed with success in 5-grain (0.33) doses. The regulation 
of the diet, and especially the disuse of alcohol and tobacco, are es- 
sential to the management of some cases, and the general health of 
the patient should always receive attention. 

Locally the indication is to remove and cleanse frequently the 
clothing of the part, and to make antiseptic and astringent applica- 
tions. Formalin solutions in the strength of from 1 to 10 per cent, in 
alcohol are of the greatest value. They should be followed by the use 
of boric acid in powder externally. Thin 2 successfully employed 
stockings and cork-soles thoroughly dried after being saturated for 
hours in a jar containing a solution of boric acid. The efficacy of 
this antiseptic measure he ascribes to the fact that the odor is the 
result of the development of Bacterium fcetidum in the secretions. 
An ointment is also employed by him for similar purposes ; it is a 
solution of boric acid in glycerin incorporated with a fatty basis of 
white wax and almond-oil, making thus a " glycerated cream of 
boric acid." Clement Hawkins 3 finely triturates 15 grains (1.) of 
red lead oxide, and to this adds gradually 1 ounce (30.) of Goulard's 
extract. This preparation is used as a lotion following a nightly 
foot-bath containing 1 ounce (30.) of alum. Radiotherapy is also 
efficient. 

Fox 4 advises a 1 per cent, solution of chloral or of potassium per- 
manganate as a topical application. Chromic acid solutions in 5 to 
10 per cent, strength, and potassium permanganate solutions in the 
strength of 1 part to 1000, may be employed. An efficacious proced- 
ure is the nightly bathing of the feet in a saturated solution of boric 
acid, followed by a thorough rubbing with alcohol ; the feet are then 
dusted with a powder containing equal parts of boric acid and tanno- 
form, with an addition of 2 per cent, of salicylic acid. If desired 
tannoform may be used alone, or talcum, or magnesium carbonate 
may be added to the combination. It must never be forgotten in 

1 Brit. Med. Jour., 1880, xviii., p. 463. 

2 Practitioner, December, 1881, xxvii., p. 2101. 

3 Brit. Med. Jour., May 7, 1881. 

4 Brit. Med. Jour., May 7, 1881. 



CHROMIDROSIS. 879 

the management of any case that the coverings of the parts affected 
must receive careful attention; treatment can be only partially suc- 
cessful if this point is neglected. 

CHROMIDROSIS. 

(Gr., xpuiia, color; v5up, water.) 
(Ephideosis Tincta, Colored Sweating, Steaebcea Nigeicans, 

PlTYEIASIS NlGEICAJSTS. ) 

By this term is indicated the condition in which effused sweat ex- 
hibits an abnormal color — yellowish, reddish, greenish, bluish, or 
blackish. Cyanideosis and Melanideosis are terms which have 
been employed to indicate blue and black sweating. The perspiration 
may be effused upon the surface already colored, or it may develop 
color by oxidation in the air, or it may be commingled with substances 
which produce the abnormal color upon the surface of the skin (bac- 
teria, dyes, chemical agents in themselves without color). The term 
Pseudocheomideosis is used by some to designate those forms in 
which after secretion the color is produced by the action of micro- 
organisms. 

Symptoms. — The most usual location for chromidrosis is the 
region of the eyes, especially the lower lids. Adjacent portions of 
the face may be involved by extension. The condition occurs less 
frequently in the axillary, crural, and genito-urinary regions, and has 
been observed upon the breast, back, and hands. Melanidrosis is the 
most common form, the predominating color presenting a variable 
admixture of brown or blue hues. Cyanhidrosis stands next in order 
of frequency, often modified by brown or yellow tints. The pigment 
material is removable with considerable difficulty, imparting to the 
cloth used a distinct smudgy stain. Oil rather than water facili- 
tates the cleansing process. The color may be diffuse or the fine 
amorphous particles of pigment may be grouped so as to give a 
punctate appearance to the part involved. In certain forms the hairs 
participate in the dyschromia. Hyperidrosis is not necessarily pres- 
ent. Whether the sweat is effused rapidly or slowly, the intensity of 
the color of the area obviously becomes greater with the accumulation 
of pigment. Subjective symptoms are practically absent. 

Etiology and Pathology. — Any age 1 and both sexes may be af- 
fected but the subjects of the disorder are usually women of a neur- 
asthenic type, and in view of the admitted rarity of chromidrosis the 
suspicion of dissimulation not infrequently arises. While it has 
been observed repeatedly in vigorous individuals, it is commonly 
found that the patient's general health is below par. Pelvic disorders 
in women have been noted in many cases. 2 We have observed chromP 

x Le Eoy de Mericourt, first to name the disorder, describes a case of rosy 
sweating in an infant. Arch. gen. de Med., November, 1857, and Bull. Acad, de 
Med., 1884, 2 e s., xiii., p. 425. 

2 N. T. Med. Jour., 1903, xxvii., p. 26. 



880 DISORDERS OF THE APPENDAGES. 

drosis with simultaneous hair coloration following the excitement of 
good news. Residence near the sea is credited with some predisposing 
tendency. An instance of red sweating is reported by Temple, 1 in a 
patient who was taking potassium iodide for syphilis. Greenish 
sweating, due to the presence of copper in the system, has been 
reported. 2 We have observed one case of this disorder in which the 
effect was produced by the copper plate of an electrode in contact 
with an abraded surface of the skin. Authors have attributed the 
color of the sweat to the presence of compounds of phosphorus, iron, 
cyanogen, hematin, chromogen, and indican in the secretion. In the 
case of the last named substance there is reason to believe that in 
many cases of cyanhidrosis, the indican is excreted in the colorless 
form (white) and changes to blue on the surface of the skin as the 
result of exudation. 

At the meeting in 1881 of the American Dermatological Associa- 
tion we exhibited the hairs of a middle-aged man that had changed 
in a night from grayish-white to a greenish and yellowish brown hue. 
White, of Boston, has observed similar cases of hair coloration as the 
result of profuse sweating. It is possible in these instances that the 
chromidrosis is produced by the mechanical washing of pigment to 
the surface by the outpouring sweat. In the case reported by Pren- 
tiss 3 of a young woman affected with an acute purulent cystitis, whose 
hair, under the influence of profuse sweating induced by the action 
of pilocarpine, changed speedily from a light blonde to nearly jet 
black hue, a similar explanation might hold were the possibility ex- 
cluded of a color change due to the excretion in the sweat of indican- 
forming substances absorbed from the focus of suppuration in the 
bladder. 

The red and yellow forms of chromidrosis are believed to be due 
for the most part to the presence of bacteria. In ten patients who 
came under our observation, five of them women, the sweat was pale- 
red to blood-red in color; the axillae were the regions involved. In 
all the cases the microscopical examination revealed similar changes. 
The hairs of the axillae were thin, pale-red, brittle, and surrounded 
with a colloid-looking, rusty or bright red sheath, in places of con- 
siderable thickness and having a rough surface. This sheath con- 
sisted of red masses presenting a radiating striation, more or less 
confluent, apparently proceeding from fibres of the cortex of the hair, 
or from some broken part of its surface. The radiating striations 
were found to be due to the aggregation of round or ovoid bacteria 
which were united in zooglea masses by a reddish intermediate sub- 
stance. Nodular swellings on the hair were produced by infiltration 
of the organism between the separated fibrils. The roots of the 
hair were free from bacteria. The red tint of the sweat was found 
to depend upon the numerous roundish masses of zooglea. 

1 Brit. Med. Jour., 1891, Aug. 29. p. 477. 

2 Clapton, Med. Times and Gazette, 1868, p. 658. 

3 Phila. Med. Times, 1881, xii., p. 385. 



URIDROSIS. 881 

Trommsdorff 1 found a yellow and a red bacterium in a case of 
red sweating of the armpits. He believes that microorganisms are 
always present in these types of chromidrosis, and that they should 
be regarded as special forms of Lepothrix (Trichomycosis palmel- 
lina — Pick). He is of the opinion that microorganisms will ulti- 
mately be found to be causally related in some instances to cyan- 
hiclrosis. 

Under the title " Seborrhea Nigricans," Mitchell 2 describes an 
unusual case of chromidrosis in which there was a dark greasy-look- 
ing discoloration of the eyelids and adjacent skin. The relation of 
the sebaceous glands to the disorder is as yet not determined. In a 
case reported by Barrie 3 the palms of the hands (free of sebaceous 
glands) were affected. In Heidingsf eld's case 4 the sweat glands were 
normal and the sebaceous glands were absent in the part involved 
(left forearm). 

In all cases, before accepting statements of patients as to the ex- 
istence of symptoms of this character, it is needful to eliminate the 
possibilities of deceit and accident. Coloring matters received upon 
the hands may be transferred either wilfully or ignorantly to the 
surface of the body. Hall 3 reports several cases in which supposed 
cyanidrosis was found to be due to cheap black stockings, the dye of 
which when brought in contact with acid sweat produced a peacock 
blue discoloration of the toes. 

Treatment.- — The treatment of chromidrosis is that of the gen- 
eral state of the patients exhibiting the symptoms. Attention should 
be directed to the gastro-intestinal tract with a view of preventing 
excessive indol formation. Locally where a parasitic source is sus- 
pected antiseptic measures may be employed. 

URIDROSIS. 

(Gt., ovpov, urine; vdup, water.) 
(Oer., Haenschweiss ; Fr., Uridrose.) 

Uridrosis is that condition in which some of the constituents of 
the urine, chiefly urea, are excreted in excess with the sweat. 

While a small amount of urea is to be recognized in normal sweat, 
this ingredient under peculiar conditions may be increased, and, to- 
gether with urinary salts, be deposited upon the skin-surface after 
evaporation of the exuded fluid. Such symptoms have usually oc- 
curred either as the result of grave constitutional affections (such as 
cholera), or of organic renal diseases accompanied by ansemia, or of 
the ingestion of jaborandi. In a few cases the symptoms have been 
presented in individuals who were apparently in good health. The 

1 Munch, med. Wochenschr., 1904, July 19, p. 1285 (with bibliography). 

2 Phila. Med. Jour., 1898, i., p. 117. 

3 Annales, 1889, s. ii., x., p. 937, with bibliography. 

* J. A. M. A., 1902, xxxix., p. 1519, with bibliography. 
5 B. J. D., 1902, adv., p. 418. 
56 



882 DISORDERS OF THE APPENDAGES. 

salts of the urine appeared upon the skins of these patients in the 
form of minute lamellae, or of a fine powder of whitish color and crys- 
talline aspect. In some cases reported the symptoms have been noted 
to precede by a few days a fatal issue. 

The constantly adjusted equilibrium between the sweat-secretion 
and the urinary excretion would explain, for cases of a mild type, 
temporary augmentation in the urea found in the sweat of unusually 
free diaphoresis. Geber supposes that decomposition-products, such 
as ammonium carbonate, possibly in association with volatile fatty 
acids, may in part account for these conditions. 

In the effort to eliminate certain substances accidentally or pur- 
posely introduced into the system the sweat may possibly become 
charged with iodine, turpentine, tar, arsenic, and other substances. 
Several of the eruptions described in the chapter on Dermatitis Medi- 
camentosa are due to a similar eliminative effort, especially those 
accompanied by excessive sweating and the production of vesiculation. 
In the same manner it may be inferred that the sweat is at times 
charged with excrementitious and other products of the body ; as, for 
example, the elements of the bile. In patients affected with yellow 
fever the skin and even the sweat which exudes from it often exhibit 
the characteristic hue of that disease. The so-called Galactidrosis, 
from supposed metastasis of milk, does not occur ; cases thus de- 
scribed have been instances of pathological sweat in the puerperal 
state. 

Phosphoridrosis, 1 in which a phosphorescent quality has been 
imparted to the sweat secretion, is reported in rare cases to have re- 
sulted from ingestion of phosphorescent fish, and in such wasting dis- 
eases as pulmonary tuberculosis, tabes, and scurvy. 

Haematidrosis (Hemidrosis, Sudor Sanguineosa, Bleeding Stig- 
mata, Neurotic Excoriations, Bloody Sweat), reported as observed by 
several authors (Foot, Ebers, Parrot), is the name applied to condi- 
tions in which blood has been seen to exude from an unbroken skin. 
The phenomena described under this title belong properly to the en- 
semble of symptoms called " haemophilia," and may in some cases be 
due to direct transudation of red and white blood-corpuscles and fibrin 
into the interepithelial spaces traversed by the sweat-pores. In a case 
macroscopically examined by Torok red corpuscles were found in the 
lumen of the coil portion of the sweat-gland. 2 Geber points to the 
neuralgic, hypersesthetic, pruritic, or emotional symptoms that are 
usual precursors to the flow of pale or bright-red blood. The fact 
that patients thus affected are mostly women, hysterical, dysmenor- 
rhceic, or near the puberal epoch, also throws light upon these cases ; 
in many of them petechias, or sighs of hemorrhage into other tissues 
of the body, are observed. It may occur obviously in any acute affec- 
tion presenting purpuric symptoms. 

1 See Mercks' case, Wien. klin. Wchnschrft., 1903, xvi., p. 1091. 
2 Mracek's Handbuch, Bd. i., pp. 416-418 (with bibliography). 



GRANULOSIS BUBBA NASI. 883 

The bleeding may occur from a single point, or from several in 
succession, or simultaneously from multiple stigmata. There may be 
a precedent elevation of the surface forming vesicles, blebs, macules, 
or papules; or the skin at the site of the hemorrhage may be un- 
altered. Gangrene has resulted in a few instances. Often pain or 
other sensations announce the occurrence of the bleeding. 

Special caution is to be taken lest patients complaining of these 
symptoms solicit the hemorrhage by self -injury. In a few cases the 
persistence of the sanguineous flow has induced a dangerous angemia. 
The treatment is that indicated by the conditions present. 

HYDRADENITIS SUPPURATIVA. 

This disorder was described in 1864 by Yerneuil, and since then 
many writers have recorded different disorders under the same 
name while other observers have described similar cases under differ- 
ent' titles. The disorder under consideration is essentially a suppura- 
tive inflammation involving the sweat apparatus. Some cases of 
Folliclis have been included in these descriptions on account of in- 
volvement in these cases of the sweat glands. 

Symptoms. — In the disorder under consideration, the common 
sites for the lesions are the regions of the axillae, anus, nipples, scro- 
tum, and labia majora. In these parts the lesions may be single or 
multiple. They may attack other regions but avoid the palms 
and soles. The lesions resemble indolent furuncles without pilo- 
sebaceous involvement. Occasionally several of the nodules coalesce 
and form a flat tumor with a number of openings. The disorder is 
chronic. 

Etiology and Pathology. — As predisposing causes should be 
counted all conditions, general or local, which tend to lower the 
vitality of the tissues. The origin is unknown, though it is probably 
to be sought in local infection or in the action of some toxic agent 
excreted by the coil-glands. 

The process has been shown to be a diffuse inflammation of the 
coil-glands and periglandular tissue, usually terminating in necrotic 
suppuration and destruction of the gland. Primarily the coil epithe- 
lium undergoes changes which are responsible for the cellular in- 
filtration of the peripheral tissue. No microorganisms have been 
recognized in the cases examined. 

Treatment.- — The general condition of the patient should furnish 
the indications for treatment of each case. Locally the nodules should 
be opened and dressed antiseptically. The disease is stubborn but 
eventually terminates in recovery. 

GRANULOSIS RUBRA NASI. 

The above title was given by Jadassohn 1 to a peculiar affection 
of the nose in children. This nomenclature' is accepted to-day; but 
*Archiv, 1901, lviii., p. 145. 



884 DISOEDEES OF THE APPENDAGES 

the disorder has been described under other headings as : "A pe- 
culiar form of acne with changes in the sweat-glands " (Luithlen) ; 
" Perisyringitis chronica nasi," and " Dermatitis micropapulosa ery- 
thematosa hyperidrotica nasi " (Jadassohn) ; il A peculiar inflamma- 
tory dermatitis of the nose of young individuals with sweating " 
(Herrmann) ; " False acne rosacea in children" (Audry) ; "A form 
of chronic erythema of the nose in children" (Dubreuilh). Since 
first described by Luithlen in 1900, the number of reported cases is 
constantly increasing. 1 

Symptoms. — The disease is a chronic inflammation of the skin 
covering the cartilaginous portions of the nose, and is characterized 
by a more or less sharply defined area of redness on which are scat- 
tered irregularly, without definite arrangement, pin-point to pin-head- 
sized, dark-red macules and papules. Interspersed among these 
lesions are beads of perspiration ; often the rounded papules are 
tipped with a droplet of sweat. The hyperidrosis of the nose is, a 
striking feature of the disease, and there is in some cases a coinci- 
dent hyperidrosis of the face and hands. Occasionally vesicles are 
found containing a clear droplet of fluid; when these are large and 
deeply seated they are not to be distinguished from the lesions of 
hydrocystoma. The redness of the area involved ranges from pale- 
pink to a purplish hue ; the color of the lesions fades on pressure ; the 
nose is cold to the touch, and subjective symptoms, aside from slight 
itching, are absent. There is usually to be found evidences else- 
where of impaired peripheral circulation. 

Etiology and Pathology. — The patients are usually children 
ranging in age between six months and sixteen years. A few cases 
have been reported in adults. Both sexes are about equally affected, 
the individuals being for the most part delicate children with poor 
circulation. Hereditary influences have been traced in some instances. 

The histological changes are those of inflammation, situated in 
the corium. The superficial blood-vessels are dilated ; about them 
and also the sweat-ducts is an infiltration consisting of leucocytes, 
connective-tissue cells, plasma cells, and occasional mast cells. A few 
leucocytes may be found in the dilated interepithelial lymph spaces 
of the rete. The pilo-sebaceous follicles are usually normal. If the 
infiltration about the sweat-duct is marked, a cyst of the proximal 
portion of the duct may be found, as in hydrocystoma. 2 

The essential factors in the production of the disorder are not 
positively recognized. It is probable that vascular disturbances are 
the primary elements in causation. Hallopeau 3 regards the disease 

1 For report of cases and discussion of the disease in general see : Audry, Jour. 
Mai. Cut., 1903, xv., pp. 809-811; Baumer, Derm. Zeitschr., 1904, xi., p. 640; 
Mirolubow, Deutsch. Med. Zeitung, 1906 Nos. 62-63; Malherbe, Jour. Mai. Cut., 
1906, xvii., p. 96; Pick, Archiv, 1902, lxii., p. 105; Herman, Archiv, lx., 1902, p. 
77; Leget, Annales, 1903, s. iv., iv., pp. 273-282; Pinkus, Derm. Zeitschr., 1904, 
xi., p. 642 ; Macleod, B. J. D., 1903, xv., p. 197, and ibid., 1906, xviii., pp. 342-353 
(excellent resume) ; Ormsby, J. C. D., 1905, xxiii., p. 183. 

2 Lebet, Pinkus, loc. cit. 

3 XV. International Medical Congress, Lisbon, 1906. Kef. in Derm. Zeitschr., 
1906, xiii., p. 573. 



SEBOBBHCEA. 885 

as a neurohyperidrosis due to disturbances of the vaso-dilators and 
vaso-constrictor nerves. 

Diagnosis. — The disease has been mistaken for lupus vulgaris be- 
cause of the gross appearance of the papules. In the disorder under 
discussion the lesions disappear under pressure, there is no tendency 
to ulceration, and marked hyperidrosis is present. From acne vul- 
garis and rosacea it may be differentiated by the absence of involve- 
ment of hair follicles and sebaceous-glands. 

Treatment. — Treatment is usually not very effectual. The gen- 
eral health should be improved by proper hygiene and the exhibition 
of indicated internal medication. Locally astringent powders, lotions 
or pastes containing resorcin, salicylic acid, ichthyol, etc., may be 
tried. Tannoform as a dusting powder has been used with consider- 
able success. Eelief by these applications is usually temporary, but 
complete disappearance of the disease may be looked for when the 
patient attains maturity. 



THE SEBACEOUS GLANDS. 
SEBORRHEA. 

(Lat., sebum, tallow; Gr. pku, to flow.) 

(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Seba- 
ceous Flux, Stearrhcea. Ger., Sciimeerfluss ; Fr., Sebor- 

RHEE.) 

The clinical phenomena which should be included under the title 
" Seborrhea " are at present in dispute. Since the time that Unna 
first placed under the caption, Eczema Seborrhoicum, a number of 
conditions which had previously been classed with Seborrhoea, the ten- 
dency has been toward a constant increase in the former category at 
the expense of the latter. This tendency is due in part to an over- 
emphasis of histology as a basis for the classification of skin diseases. 
While it is unquestionably true that the microscope will often dis- 
cover the evidences of inflammation where clinically no signs of that 
condition are manifest, it would seem best for the present, until our 
knowledge of the factors concerned becomes more accurate, to make 
the basis of classification in this instance clinical rather than histolog- 
ical. Under Seborrhea, therefore, will be described those conditions 
which are non-inflammatory as far as is evidenced by the clinical ap- 
pearances. Those seborrheic disorders which clearly show the signs 
of inflammation are considered under Dermatitis Seborrhoi'ca. 

It must be borne in mind that this classification is somewhat arbi- 
trary and is chosen with a purpose — to make as clear as possible to 
the student an obscure portion of dermatology. It does not assert 
that, histologically, traces of inflammation cannot be demonstrated in 



886 DISORDERS OF THE APPENDAGES. 

the disorders described, nor does it fail to recognize that clinically a 
simple seborrhcea may become distinctly inflammatory under proper 
conditions of irritation. 

Symptoms. — Seborrhoea occurs in two forms. According to the 
condition of the excreted product, they are described as seborrhoea 
oleosa and seborrhoea sicca. These two forms are recognized clinic- 
ally as of separate occurrence, yet the dividing line between them is 
not clear-cut, since the oily form, by inspissation and crusting of the 
excessive secretion present, may pass clinically into the dry variety. 

Seborrhcea Oleosa. — This form of seborrhoea, variously known as 
hyperidrosis oleosa (Brocq), seborrhoea simplex (Unna), stearrhoea 
simplex (Wilson), acne sebacee fluente, etc., is in its pronounced fea- 
tures rarer than seborrhoea sicca, but in lesser degree it is a condition 
sufficiently common. The sebaceous secretion is exuded as an oily 
fluid upon the surface both of the hairy and so-called " non-hairy " 
parts of the skin. In the former situation, both in adults and in- 
fants, the free oily substance is seen to cover as a coating both skin 
and hairs, and especially in adults who have suffered much loss of hair 
as a result of the sebaceous disorder, to produce a glistening and 
shining appearance of the scalp. In women with long hair the locks 
are often matted together in a glue-like paste. The same greasy 
layer can be seen over the non-hairy portions of the skin, especially 
about the nose, forehead, and cheeks. Free drops of oil can occasion- 
ally be wiped from such surfaces with a handkerchief. The ducts of 
the sebaceous follicles here are either patulous or plugged with sebum ; 
the skin-surface may be slightly reddened or be pallid, but it is usu- 
ally cold to the touch. The oily substance serves to entrap particles 
of dust, soot, etc., floating in the air ; thus a peculiarly dirty or even 
blackish hue of the face is often produced. This form of seborrhoea, 
though most common on the face and scalp, may occur on the chest, 
the back, the pubes, the genitals, and rarely on the other parts of the 
body. In the negro, in whom the sebaceous elands are usually well 
developed and active, the oily form of seborrhoea is common, and the 
flux at times is practically physiological. Subjective symptoms in 
seborrhoea oleosa are usually slight, though a moderate, amount of 
itching is commonly present. 

Seborrhoea Sicca as the term is generally accepted, varies greatly 
in its manifestations, but in general its features may be divided into 
the scaling and the crusting form of the disease. The scaling form, 
variously known as seborrhoea furfuracea or pityriasiformis, pity- 
riasis simplex, eczema seborrhoi'cum, eczema squamosum, etc., is most 
common on the scalp, in which region it is popularly known as 
" dandruff." Seborrhoea capitis in its commonest form is recog- 
nized in the adult by the formation on the scalp, of fine, branny, 
slightly greasy, white or grayish scales, which may be so abundantly 
shed as to fall freely and cover the shoulders of the patient whenever 
the hair is brushed or otherwise disturbed. At other times these fatty 
scales are more or less adherent to the scalp-surface, or are piled up in 



SEBOBEHCEA SICCA. 887 

laminae one upon another. These scales may mat the hairs to the 
scalp or be disseminated through the mass of the hair, some of the 
hairs penetrating a flattened greasy scale, as a twig might be passed 
through the centre of a leaf. In consequence of their deprivation of 
unguent the hairs to which the affected glands are accessory become 
dry and lustreless. Some degree of alopecia is invariably present; 
this fortunately is usually symmetrical. 

The affection may be circumscribed, and in conspicuously ex- 
hibited patches covered by scales ; or it may extend uniformly over the 
entire surface of the scalp, or, as is frequently noticed, may fringe the 
brow at the line of the hairs and then extend chiefly over the vertex, 
being conspicuous at the line where the hairs are parted from vertex 
to brow. Beneath the scales or crusts of dried sebum the scalp is 
usually lustreless and a slate-gray color. The disease not infre- 
quently extends from the scalp to the adjacent portions of the face, 
neck, and ears. In these situations the skin may be slightly red- 
dened, while the scales are thin, adherent, and not very abundant. 
The eyebrows, the region covered by the beard, and the pubic hairs 
may be affected, although less frequently, in the manner described 
above. In the latter region the itching is often more severe than 
when limited to the scalp. The disorder may appear on the portions 
of the face more distant from the scalp, and on other parts of the 
body, in the form of dry, roughened patches which scale more or less, 
but which are only slightly, if at all, reddened. On any of these sur- 
faces the condition may shade insensibly into those described under 
dermatitis seborrho'ica. 

The crusting forms of seborrhea may occur on any of the hairy or 
non-hairy parts of the body, but are most common on the scalp and 
face. The so-called " waxy " form is represented by the physiological 
vernix caseosa of the newborn infant, and by the more or less adherent 
dirty-yellowish cap often long surviving upon the vertex of young in- 
fants. Occurring later in infancy, the disease is known as "milk- 
crust," or as crusta lactea. This may merely be persistence of the 
dried vernix caseosa about the vertex in the newborn, or it may occur 
in scalps which have been perfectly cleansed after birth. The crust 
differs somewhat in color with the tint of the child's complexion, and 
may vary from a light yellow to a dark brown ; it may be thick, greasy, 
and mat the hairs ; or be thin, dry, and friable. Inflammatory com- 
plications are very prone to develop from decomposition of the mate- 
rial making up the crust, in which event the disorder becomes prop- 
erly a dermatitis seborrhoi'ca. The region of the brow, the surface 
covered by the beard of the male, and the pubic hairs may be involved 
in this type of the disease, though less frequently than in the furfur- 
aceous form. 

On the face this form of seborrhoea is characterized chiefly by the 
accumulation of thick, dirty-yellowish and even yellowish-black accu- 
mulations of sebaceous matter, often adherent to the surface and 
disfiguring the features by the mask produced. This condition is 



888 DISOEDEES OF THE APPENDAGES. 

conspicuous about the nose, where the disease is at times symmetric- 
ally disposed. The crusts once removed, the skin beneath is generally 
found to be pallid or slightly reddened, with the orifices of the seba- 
ceous ducts patulous ; while the under surface of the separated crust 
is seen to project downward in corresponding delicate prolongations 
comparable to stalactites. The crusts rapidly reform when the disease 
is not arrested. They are found in the furrows on either side of the 
nostrils, on the brows, the cheeks, and the pavilion of the pinna of the 
ear. They are most common at the puberal epoch in both sexes when 
the sebaceous glands of the skin undoubtedly sympathize with the 
changes occurring at the beginning of the sexual life. 

Seborrhcea may affect the eyelids, in which situation a mild derma- 
titis seborrhoi'ca usually supervenes, owing to the trauma of rubbing 
and the incessant movement of the skin in winking. The lids are 
then reddened, slightly swollen, and in various degrees covered with 
minute crusts (less frequently with scales). The eyelashes often fall 
and in cases of long standing their loss may be permanent owing to 
atrophy of the follicles. 

Seborrhcea of the umbilicus assumes special features in that the 
fatty matters in this region are remarkable for their tendency to 
speedy decomposition, with the production of an exceedingly fetid 
odor and a mild degree of seborrhoi'c dermatitis. 

Seborrhoea of the genitals in men is usually located in the sulcus 
behind the corona glandis though in individuals with a tight or a re- 
dundant prepuce it may become more extended. In women the ac- 
cumulation occurs about the clitoris and vestibulum, though the exter- 
nal labia may be covered with the secretion in various degrees of 
fluidity. The smegma preputii supplied by the glands of Tyson may 
thus be a source of trouble either by its retention, or by its secretion 
in abnormal quantity or quality. In either event the tendency is to 
decomposition, fetid odor, and subsequent irritation, which may lead 
to an inflammation of severe grade. 

Seborrhoea Squamosa Neonatorum {Ichthyosis Sebacea). — This con- 
dition in the newborn is probably not a seborrhoea. The body at birth 
is covered with a greasy layer noi unlike paraffine paper in appear- 
ance; beneath, the skin has a varnished, reddish-brown appearance. 
Owing to the stiffening of the integument fissures are prone to de- 
velop, and these about the mouth may lead to malnutrition from in- 
ability to take the nipple. The layer tends to renew itself in part 
after removal, but eventuallv the desquamation ceases and the skin be- 
comes normal. Bowen 1 regards the condition as a persistence of the 
epitrichial layer of the embryo which is normally cast-off in atero 
at the seventh month. 

In adults the disease may occur in marasmic subjects and in old 
people in the form of a persistent fine scaling on the trunk and exten- 
sor surfaces of the limbs, and is known as " Pityriasis Tabescentium." 
A yet rarer form is described by Kaposi under the name of " Cutis 

1 J. C. and G.-TT. Dis., 1895, xiii., p. 485. 



SEBOBEHCEA. 889 

Testacea," in which large portions of the skin, especially the exten- 
sor surfaces of the limbs, are covered with greenish-brown or blackish 
crusts which are more or less broken up into plates. 

Etiology. — Seborrhcea, except that form which appears in in- 
fancy, is most frequent at the age of puberty or in young adults — that 
is, at the time of greatest activity of the glands. It may appear, how- 
ever, at any age. It occurs about equally in both sexes. The com- 
monest seats of the disease are : the scalp, the face, the genital region, 
the dorsum of the body between the scapulas, and the anterior sur- 
face of the chest ; all of these are regions where the oil glands are 
especially numerous and well developed. Seborrhcea oleosa is found 
more frequently in persons of dark complexion, while seborrhcea sicca 
is more common in blondes. A family tendency to fu'rfuraceous 
seborrhcea of the scalp, with the resulting alopecia, may often be 
noted. 

Among the predisposing causes may be counted all systemic dis- 
turbances which lower the vitality and general nutrition. Seborrhcea 
may thus follow acute infectious diseases, and frequently appears 
during the course of chronic exhausting diseases, such as syphilis or 
tuberculosis. Constipation, indigestion, sedentary habits, and the ex- 
cessive use of alcohol and tobacco, may be classed as predisposing 
factors. The disease occurs, however, in individuals who are appar- 
ently in excellent health. Among the local predisposing causes are 
the wearing of stiff, heavy, and ill-ventilated hats, and the failure 
properly to care for the scalp. Women with long hair are generally 
obliged to bestow special attention upon the scalp. Men with short 
hair attend chiefly to its disposition upon the head, and because this 
is so easily accomplished often neglect the care of the scalp. Such 
neglect is followed frequently by seborrhcea sicca when no other cause 
for the disorder can be found. Both varieties of seborrhcea are fre- 
quently found, often with inflammatory complications, in nuns with 
whom the scalp, ears, and neck are encased snugly in stiff, unventi- 
lated head-dresses. 

While there is much, both in clinical experience and in laboratory 
findings, to commend the theory that seborrhcea is of parasitic origin, 
no one microorganism has yet been demonstrated to have a definite 
etiological relation to the disease. Moreover, the sebum retained in 
the follicles furnishes an excellent culture-medium for an unusual 
development of microorganisms which may be found on the scalp in 
normal conditions. Schamberg 1 has demonstrated Sabouraud's micro- 
bacillus in the follicles of individuals having no signs of seborrhcea or 
of other diseases of the sebaceous glands. 

Pathology. — Although the pathology of diseases of the sebaceous 
glands, including seborrhcea, comedo, acne and acne rosacea, has been 
studied by many competent observers, there yet exists a diversity of 
opinion regarding the nature and pathogenesis of these affections. 
The conservative view, based on the teachings of Hebra, is that sebor- 
1 J. C. D., 1902, xx., p. 99. 



890 DISOBDEES OF THE APPENDAGES. 

rhea is a functional disease of the sebaceous glands, manifested in 
hypersecretion of pathologically altered sebum, and often accompanied 
by some hypertrophy of the glands. In the oily form, the sebum is 
secreted in excessive quantities and may be more fluid than normal. 

As a rule at puberty, and in some individuals throughout their 
lives, the quantity of oily sebum excreted is larger than usual, and 
it is not always possible to draw sharply dividing-lines between the 
physiological and the pathological process. In the dry form of sebor- 
rhea the secretion is dryer than usual and mixed with cells exfoliated 
from the ducts of the glands and hair-follicles, and with imperfectly 
metamorphosed cells from the glands themselves. Unna 1 believes 
that the skin is lubricated by oil from the coil-glands, and that in 
seborrhea oleosa (which he terms liyperidrosis oleosa) the secretion is 
practically all furnished by them, the sebaceous glands being involved 
if at all secondarily. Beatty 2 states that the coil-glands do not fur- 
nish the oily secretion in this condition. Sabouraud 3 concludes that 
seborrhea oleosa (also comedo, acne, and alopecia areata) is due to an 
inflammation of the sebaceous glands, caused by a definite micro-bacil- 
lus which is found within a cocoon-shaped mass of epithelium at the 
neck of the follicle. 

It is generally believed that the coil-glands secrete fat, but how 
much they supply and what part they play in seborrhea are unsettled 
questions. The fact that seborrhea is most frequent and most pro- 
nounced in regions where the sebaceous glands are largest and most 
numerous is fairly good evidence that these glands more than the 
sweat-glands are active in the production of the disease. 

In seborrhea sicca the scales are produced from the horny layer of 
the scalp and not from the gland. This fact was demonstrated by 
Hardaway in 1878, and since that date by Unna, Sabouraud, and 
others, and is an argument that the disease is essentially inflamma- 
tory. Sabouraud states that simple pityriasis of the scalp is due to a 
flask-shaped bacillus and to a coccus producing gray cultures. The 
lesions with greasy scales he thinks are the result of superficial inflam- 
mation, added to preexisting seborrhea oleosa. Unna finds in sebor- 
rhea sicca several microorganisms (see Dermatitis Seborrho'ica) 
which he believes to be the cause of the disease. 

Unna and Elliott state that the microscope shows inflammation 
to be present in all but the simple oily form of seborrhea. As stated 
before it is difficult to draw sharply dividing-lines between the types 
here described which clinically show little or no evidence of inflamma- 
tion, and the distinctly inflammatory forms described as dermatitis 
seborrho'ica. 

Diagnosis. — Seborrhea is to be distinguished from eczema, derm- 
atitis seborrho'ica, ichthyosis, impetigo, psoriasis, syphilis, and tinea 
tonsurans. The distinctly inflammatory character of the first two 

*B. J. D., 1894, vi., p. 257; and Histopathology, p. 222. 

2 Brit. Med. Jour., 1901, ii.. p. 858; and Les Maladies du Cuir chevelu, Paris, 
1902. 

•B. J. D., 1894, vi., p. 161. 



SEBORBHCEA. 891 

serves to differentiate them. In ichthyosis, the scale is dry and non- 
greasy; the disease is congenital, usually involving the entire body, 
while seborrhcea is generally acquired and is rarely universal. Crust- 
ing impetigo of the scalp might be confused with seborrhcea ; the for- 
mer is an acute disease, its lesions are comparatively small, circum- 
scribed, and isolated, the crusts differ in character from the sebaceous 
matter formed in seborrhcea, and the skin beneath is reddened and 
evidently the seat of an exudation. Psoriasis of the scalp may be 
recognized by the presence of typical patches upon the body; the 
scales are lustrous, larger, and not greasy unless some fatty applica- 
tion has been made to soften them ; they cover a reddened integument 
beneath ; and alopecia is not produced even in persistent cases. Some 
of the pustular syphilodermata located upon the scalp and face, if 
observed only in the stage of crusting, might be confounded with se- 
borrhcea ; but the history of the case, the discovery of other signs of 
syphilis, such as adenopathy, mucous patches, etc., the character of the 
secretion, the condition of the surface beneath the crusts, and the 
small size, more definite outline, and characteristic grouping of the 
lesions should point to the identity of the disease. Tinea tonsurans 
may be recognized by the non-greasy character of the scales upon the 
affected patches, which are usually circumscribed and circular; the 
hairs in the areas involved are fragile and often appear as broken off 
stumps, in which the presence of the parasite is shown by the micro- 
scope. 

Treatment.- — The general and internal treatment of seborrhcea 
should be varied to meet the requirements of the individual case. 
The preparations most often indicated are: iron in anaemic young 
women, cathartics in sluggishness of the bowels, and cod-liver oil and 
the bitter tonics when there is impairment of nutrition. Arsenic, 
employed in the manner suggested by Sir Erasmus Wilson, is praised 
by Hebra: 

fy Vin. ferri, fgjss; 45 1 

Liq. potass, arsenit., ) __„_.. ol 

Syrup, simpl., \ aa f5 ^' 8 I 

Aq. destill., f^ij; 60] M. 

Sig. A teaspoonful to be taken three times daily with the meal. 

In many cases the acid iron mixture of Startin, or some modifica- 
tion of it, admirably meets the indications. 



33 

M. 
Sig. A teaspoonful in water, to be taken through a tube after eating. 

Throughout the treatment the physician should insure a care- 
ful observance of the laws of hygiene. Sunlight, nutritious food, and 
open-air exercise are not to be disregarded. When the scalp is in- 
volved the patient should be encouraged to discard the hat so far as 



Magnes. sulph., 


ftj; 


60 


Ferri sulphat., 


3ss-3j; 


0.66-1 


Acid, sulph. dilut., 


f3ij-f3iv; 


8-16 


Infus. quassise, 


ad f^iv; 


120 



8 ( J2 DISORDERS OF TEE APPENDAGES. 

possible, consistently with the circumstances in which he may be placed, 
and thus promote the favorable action of light and air upon the part 
affected. In cases in which it can be tolerated, daily cool salt-and- 
water sponging of the entire body-surface, followed by brisk friction, 
as described under the treatment of acne may be employed with great 
advantage. 

The first indication to be met by local treatment in seborrhcea is 
the removal of the crusts and the fatty matters accumulated upon 
the surface. It is always well to warn patients, especially if the dis- 
order be upon the scalp in an aggravated form and occur in young 
women with apparently luxuriant tresses, that a considerable loss of 
hair will result. Many of the hair-filaments are so impoverished by 
the disease and so loosened in their follicles that a complete cleansing 
of the scalp-surface will bring the hairs away in quantities sufficient 
to threaten speedy baldness ; and it is not rarely the case that patients 
attribute this to the treatment rather than to the disease. The fatty 
accumulations are first to be soaked with some oily fluid to facilitate 
their removal ; for this purpose olive-oil, vaselin, almond-oil, glycerin, 
or lard is usually employed. The substance selected should be used 
in quantity sufficient to permeate all crusts. It may be poured over 
or be rubbed into the scalp several times in the twenty-four hours, 
and at night a flannel or other cap should be worn. In the case of 
children and infants gentleness is required in thus treating the 
scalp, especially in the subsequent washings, lest the surface be irri- 
tated. In women it is rarely necessary to cut the hair. As soon as 
the soaking with oil is complete the crusts are to be removed by 
washing with soap and water, though when the accumulations are 
bulky, masses may be gently removed with the fingers or a comb. 
When the scalp is tender, ordinary toilet or Sarg's glycerin soap may 
be applied with warm water; but it is usual, in the case of 
adults, to employ the well known tincture of green soap. The sur- 
face should be thoroughly sponged with the tincture, and then warm 
water added until with gentle rubbing, lather is abundantly produced 
over the scalp, when an excess of water is finally used to cleanse the 
part of crusts, oil, and soap. The scalp and hairs are then thoroughly 
dried and anointed with some bland, fatty substance if the exposed 
surface be tender and irritable ; if not, with some stimulating pomade 
or lotion. 

In cases in which milder effects are required the scalp may be 
washed with water containing such alkaline substances as borax, 
ammonia, or potassium carbonate. The popular prejudice against 
these articles is based upon the abuse of strong alkaline lotions in the 
hands of inexperienced persons. Such lotions may readily be tested 
by the tongue before use upon the scalp. They should in all cases 
be followed by an oily or greasy application medicated to meet the 
requirements of the case. Tar soap may be used at times with ad- 
vantage for cleansing the scalp ; the compound tincture of green soap 
of the National Formulary (1906) is a preparation so medicated and 
may be applied in the same manner as the simple tincture. 



SEBORRHEA. K93 

Though seborrheic crusts may be extensive, it is possible to re- 
move them completely in every case by the measures described above, 
and with the first treatment patients are often delighted. Not in- 
frequently their disappointment is correspondingly great when they 
discover that the seborrhoea is not at an end, and that in the course 
of a few days the fatty plates are as freely as ever deposited on the 
scalp, disseminated through the hairs, and showered upon the shoul- 
ders. Some will even declare that the soapy applications aggravate 
the disorder by increasing the seborrhoea. It should, therefore, 
never be forgotten that, having disposed of the extraneous matters 
accumulated upon the surface, there is still to be remedied a func- 
tional disorder of the sebaceous glands of the part. 

In every case, then, after the use of soap and water, which may 
be repeated as often as need be, daily, at intervals of several days, or 
once a week, the scalp is to be thoroughly anointed. For this pur- 
pose olive-oil, cod-liver oil properly scented, almond-oil, vaselin, or 
glycerin and water may be used. Van Harlingen recommends, as a 
substitute for other oils, the oleum sesami (oil of benne), since it does 
not dry and clog as do the former. An ounce (30.) of this oil rubbed 
up with 5 grains (0.33) of powdered benzoin, and digested for three 
hours over a water-bath, with the addition of 3 drops of absolute 
alcohol, and filtered, furnishes an excellent basis for oily mixtures to 
be used on the scalp. Any of these applications can be made con- 
veniently with a medicine-dropper. Crocker advocates the use of a 
lotion containing acetic acid, prior to the application of oily prepara- 
tions to the scalp, the object being to aid the penetration of the 
remedy. 

In the place of oils after these ablutions, pomades are often used 
with more advantage. For this purpose vaselin, lanolin, lard, and 
cold cream ointment furnish the best bases. To obtain the desired 
consistency, any one of these may be used alone or in combination 
with the others or^with an oil. 

Of the many substances employed and recommended as medica- 
ments for these pomades, sulphur, resorcin, salicylic acid; and the 
red oxide, the red sulphuret, and the ammonio-chloride of mercury 
are most serviceable. 

Sulphur is of great value in the treatment of all sebaceous gland 
disorders; in the form of an ointment, 15 grains (1.) to a drachm 
(4.) to the ounce (30.) of vaseline or other ointment-base. One-half 
the quantity, or as much, of resorcin may often be added with advan- 
tage to the pomade. The alterative effect of the mercurials is also 
as evident in seborrhoea as in many other cutaneous disorders. At 
the head of the list, for this special purpose, stands the red mercuric 
oxide in strength of from 2 to 4 grains (0.133-0.266) to the ounce 
(30.) of ointment; but ammoniated mercury, and calomel in the pro- 
portion of from 5 to 10 grains (0.33-0.66) to the ounce (30.), may 
be often substituted for the former with advantage. The tars are 
useful in many obstinate cases; oleum rusci may be added in the 



894 DISORDERS OF THE APPENDAGES. 

strength of 1 to 10 parts to any of the salves recommended above. 
Ichthyol in ointments of the strength of from 5 to 10 per cent, has 
also proved efficacious. An excellent formula for the scalp is the 
following : 

# Sulphur, praecipit., 5j; -±| 

Lanolin., -^ 

Glycerin., L aa 3ijss; 10[ 

Aq. rosas, J 

Saponis, 3ss; |66 M. 

Sig. Ointment for scalp. 

Lotions are well adapted to some cases ; they are cleanly and easy 
of application, and are more pleasing to most patients, especially to 
women with long hair. Their efficacy is often enhanced by the addi- 
tion of a small amount of oil. Mercuric chloride is admirably 
adapted for use in lotions ; so also are tincture of cantharides, capsi- 
cum, mix vomica, and the salts of quinine. A good formula is as 
follows : 



133 



I£ Eesorcin., 


5ijss; 


10 


Hydrarg. bichlorid., 


g r - ij; 




01. amygdal. dulc, 


3ij; 


8 


Tinct. cantharid., 


5ij; 


8 


Spts. vin. rect., 


3ij; 

q. s. ad f 5vj; 


60 


Aq. destill., 


180 


Sig. To be rubbed into the scalp. 







M. 



For this may be substituted \ ounce (15.) of resorcin in 2 ounces 
(60.) of alcohol and 6 ounces (180.) of rose-water. 

Often the combined use of a pomade and a lotion is advantageous. 
A convenient procedure is to have the patient shampoo the scalp once 
a week ; after the hair is dry a pomade suitably medicated is applied 
with the finger tips, and on each of the intervening six days before the 
next shampoo a lotion is employed upon the scalp with the aid of a 
medicine-dropper. 

Repeated applications and patient care of the scalp are necessary 
to secure complete relief in the case of a disease as essentially chronic 
as seborrhoea. At times the local treatment may be changed with 
advantage. Xot infrequently too vigorous treatment is followed by 
a more or less acute dermatitis. In this case stimulating prepara- 
tions should be replaced by soothing ointments or lotions until the 
induced inflammation has subsided. 

The treatment outlined above for the hairy portions may be 
used with success also for the relief of seborrhoea of the non-hairy 
portions of the body, especially the face. Here, it will be observed, 
the crusts have a tendency to re-form, and the most persistent treat- 
ment is necessary to secure permanent relief. Occasionally, after 
cleansing the surface with soap and spirit-lotions according to the in- 
dications of each case, it is of advantage to apply the ointment se- 
lected for subsequent application, not only by gently smearing it on 
the parts with the tips of the fingers (always the most effective 



SEBORRHEA. 895 

method), but also by spreading it on a compress, which, for the night 
at least, may be fixed in contact with the part. Unna's lead-plaster 
mulls, used for this purpose in Germany, may fairly well be imitated 
by drawing strips of cheesecloth through heated diachylon ointment 
and then smoothly smearing them with the same material. When the 
tendency to re-formation of the crust is abated one or more of the 
dusting-powders may at times be employed with advantage for the 
purpose of protecting the skin or of exercising upon it an astringent 
effect. Sulphur and salicylic acid are especially valuable in these 
dusting-powder combinations. 

Seborrhoea oleosa is best treated with lotions or with powders. 
Should the skin become irritated under these applications, ointments 
may be substituted for a time. Astringent lotions or powders con- 
taining tannin, zinc sulphate, zinc oxide, bismuth subnitrate, sulphur, 
salicylic acid, tannoform, etc., are often serviceable. 

The local treatment of seborrhoea of the genitals is somewhat dif- 
ferent. Ointments rarely answer well in disorders of the mucous 
surfaces, and green soap is too irritating for similar employment. 
Here washing with a good toilet-soap and warm water is sufficient for 
the purposes of cleanliness, and diluted lotions containing alcohol, in 
the form of whisky, brandy, or aromatic wine, suffice. These lotions 
can be made astringent with tannin, alum, or zinc sulphate, and when 
there is pain or tenderness opium may be added. In this form of 
the disease, as also in seborrhoea of the umbilicus, carbolic acid or 
chlorinated soda may be necessary to correct fetor. After the em- 
ployment of these lotions boric acid with talc (1 part to 4), or zinc 
oxide (1 part to 8), may be dusted over the part. 

In the condition described as ichthyosis sebacea in the new born 
the body must be kept anointed with oils or fats. Artificial feeding 
may be demanded by the condition of the mouth. 

Prognosis. — In forming a prognosis in cases of seborrhoea of the 
scalp it must be remembered that the disease is frequently obstinate, 
and shows a decided tendency to recur unless some treatment be con- 
tinued for weeks or months after the scalp is apparently well. The 
resulting loss of hair, if symmetrical, may be remediless, but much 
may be done in the way of saving the hair which is left. Facial 
seborrhoea is much more amenable to treatment; seborrhoea of the 
genitals and the umbilicus is an entirely manageable disease. 

DERMATITIS SEBORRHEICA. 

(Eczema Seboeehoictjm. ) 

Duhring was the first observer to show that a type of inflammation 

of the skin, to which he gave the name seborrhoea corporis, was 

closely allied to, and usually consecutive to, seborrhoea capitis. Later, 

Unna 1 advanced the theory that a single morbid process, to which 

1 Monatshef te, 1887, vii.; and Histopathology. 



896 DISORDERS OF TEE APPENDAGES. 

he gave the name, eczema seborrhoicum, is responsible for a number 
of varied clinical manifestations which had previously been consid- 
ered separate disorders. Under this title he includes seborrhoea 
sicca (or pityriasis) of the scalp, face, and body, some chronic circum- 
scribed forms of eczema, and many cases which most observers still 
believe arc forms of psoriasis. In America Elliott has furnished an 
excellent presentation of the subject. 1 

Though Unna gave eczema seborrhoicum a wider range than 
is accepted by the majority of dermatologists, there is little doubt that 
the most of the phenomena he describes under that title are inti- 
mately related etiologieally and pathologically. It must be said that 
the tendency to-day is toward his position, though it is doubtful if 
his views in their entirety will ever attain full acceptance. Follow- 
ing Unna, the term, by many authorities, is made to include certain 
seborrheic disorders which are non-inflammatory in the sense that 
the clinical signs of inflammation are absent. These same disorders, 
however, may show histologically, distinct though perhaps slight, 
evidences that the pathological process is inflammatory. It is mani- 
festly not easy to mark accurately the dividing line between the in- 
flammatory and the functional in these instances without the aid of 
the microscope. As the term itself implies an inflammatory complex 
the expedient course would seem to be to make the division between 
seborrhoea and eczema seborrhoicum purely clinical ; in other words, 
to place in the former group those disorders which show no clinical 
sign of inflammation, reserving for the latter group those which are 
manifestly inflammatory. 

Many of the conditions described under eczema seborrhoicum 
arise from the implantation of an inflammation upon an ordinary 
seborrhoea, as the result of some form of external irritation. Promi- 
nent among these exciting factors must be mentioned the decomposi- 
tion of the excessive sebaceous secretion upon the uncleansed or im- 
properly cleansed skin ; but it cannot be denied that any dermatitis 
produced by whatever irritant, may, in individuals with a tendency 
to functional disturbances of the sebaceous glands, take on a sebor- 
rhceic character. This fact viewed in the light of the present-day 
conception, that the difference between eczema and dermatitis is 
largely etiological, argues in favor of a change in nomenclature from 
eczema seborrhoicum to dermatitis seborrhoica. 

The eczema seborrhoeicum of Unna, therefore, narrowed by the 
eliminations of clinically non-inflammatory forms, is here described 
under the name Dermatitis Seborrhoica. 

Symptoms. — Dermatitis seborrhoica almost invariably begins on 
the scalp and often remains limited to this region, though frequently 
it extends to the ears, temples, forehead, neck, and adjacent parts. 
The disease is not uncommon on other parts of the body where the 
sebaceous glands are large and abundant, as in the sternal, interscapu- 
1 Morrow's System, iii., p. 273. 



DEEM ATI TIS SEBOBEHOICA. 



897 



lar, inguino-scrotal, axillary, and umbilical regions. It may appear, 
however, on any part of the body and in rare instances is universal. 
The disease is extremely variable in its course and mode of extension. 
It may remain confined to the scalp for years and then extend to 
adjacent surfaces, or appear on portions of the body distant from the 
scalp, leaving the intervening surfaces unaffected. Such spreading 
of the disease may be very rapid, or so slow as to be almost inappre- 
ciable, while the lesions may be numerous, extensive, and acute in 
type, or few, scattered, and indolent in character. 

The affection varies considerably in appearance in its different 
phases and especially in different regions. In the scaly form, which 
is the most common, there is a scanty or abundant formation of fine 
branny scales; the skin is somewhat reddened, and often has the 
peculiar yellowish color which is characteristic of the disease. The 
scales may be large and abundant, and heaped up in dry, adherent 



Fig. 182. 




Dermatitis seborrhoi'ca. 



masses, simulating those sometimes seen in psoriasis, but in such 
cases the scales are usually somewhat fatty. Frequently there is a 
coexisting seborrhoea oleosa, with the formation of yellowish to brown- 
ish, soft, greasy, and non-adherent masses, suggesting crusts rather 
than scales, under which the skin is more or less reddened and the 
mouths of the follicles patulous. 
57 



898 



DI SOU DEES OF THE APPENDAGES. 



The disease often appears in the form of oval or rounded macules 
and patches, or as small scale-capped papules which may remain dis- 
crete or may coalesce to form slightly elevated plaques. The macules, 
papules, and plaques are sharply outlined, and patches that are 
spreading peripherally frequently present a circinate border with a 
fading yellowish centre. By the coalescence of several such areas 
polycyclic, gyrate bands may be produced. The color of the lesions 




Dermatitis seborrho'ic 



is reddish or pinkish, modified by the yellow tinge that is nearly 
always present. Scaling and crusting in varying degrees are usually 
present as in the more diffuse forms described above. The lesions 
may occasionally be moist over all or parts of their surfaces, but the 
characteristic vesicles and pustules of eczema are absent and the dis- 
charge when present is usually distinctly greasy. Of the varied mani- 
festations of the disease the scaling forms are the most common, but 
in a given case the type may change gradually or rapidly, and multi- 
formity of lesions is not unusual. Itching is usually slight and may 
be absent. 

On the scalp the onset of the disorder is particularly insidious 
and often unnoticed until attention is attracted to it by a thinning of 
the hair, moderate or really annoying pruritus, and a scanty or abun- 
dant formation of scales over more or less of the scalp. In the early 



DEEMATITIS SEBOERHOICA. 899 

and mild forms the condition is practically that described under 
seborrhea sicca ; the point of emergence from the latter condition into 
a dermatitis seborrho'ica is here considered as marked by the ap- 
pearance of the clinical characteristics of inflammation. The vertex 
is the usual site of the affection, but the entire scalp may be involved. 
The scales may appear in any of the forms described above, but are 
usually fine, dry, grayish, and slightly greasy. The lowest layers of 
the scales are usually firmly attached to the underlying surface, which 
at first dry, lustreless, and pale, becomes more or less hyperaemic. 
After the condition has existed for a time alopecia is noticed, while 
the hairs of the affected regions are dry and lustreless. The condi- 
tion may persist for months or years with but slight change. In 
more severe forms the heavier masses of scales and crusts described 
above may occur upon distinctly reddened or moist patches. Sebor- 
rhea oleosa may complicate the process with its characteristic greasy 
crusts and oily condition of scalp and hair. Itching is usually quite 
severe, and the inflammatory features of the condition are aggravated 
by the trauma of scratching. In infants and occasionally in adults 
a genuinely acute dermatitis may supervene, involving portions or 
all the scalp and usually extending to the adjacent portions of the 
face. The condition known as Milk-crust (described under Sebor- 
rhea) passes into a form of dermatitis seborrho'ica when inflamma- 
tion is produced by irritation from decomposition products in the 
material accumulated upon the scalp. In adults circumscribed, oval 
or circinate, reddened, and scaling, moist, or crusted patches may ap- 
pear, chiefly at the nape of the neck and about the temporal and 
parietal regions, often extending to the ears and portions of the face. 
Occasionally a sharply defined red band, more or less covered with 
scales or small crusts, may be seen at the margin of the hair, espe- 
cially on the forehead and on the neck. Such bands closely resemble 
those of psoriasis, but usually have a more regular and even outline ; 
much less infiltration and thickening of the skin, and lack the charac- 
teristic scales and outlying separate lesions of psoriasis. 

The ears and the surfaces surrounding them are, after the scalp, 
more frequently involved than other parts of the body. Any of the 
above-described types of the disease may be seen in this region, the 
moist and crusting forms being quite common, especially back of the 
ears, where fissures frequently occur. The disorder not rarely affects 
to a very marked degree the lining of the external conduit of the ear, 
blocking it with crusts and interfering seriously with audition. 

The beard, moustache, eyebrows, and pubes may present symptoms 
differing but slightly from those in the scalp. The disorder may 
linger about the verge of the moustache or other parts of the beard, 
showing its grease and scales even at a distance from the line of hairs, 
with a well-defined reddened surface beneath. The same occurs about 
the line of the eyebrows. Alopecia is uncommon in any of these 
regions except the eyebrows. 



900 DISOFDESS OF THE APPENDAGES. 

On the face the pityriasic forms with a moderate degree of redness 
are common on the nose and adjoining portions of the cheeks, the eye- 
brows and the region between, the eyelids and their margins, and may 
be exhibited on any part of the face. The more inflammatory moist 
and crusting types are most frequent along the junction of the alae 
of the nose with the cheeks, but may involve the entire nose and other 
parts of the face. The macular and papular types, above described, 
are most common on the cheeks. 

Seborrhcea Corporis, — Upon the trunk is frequently found Unna's 
" flower-leaf " or " petaloid " type of the eruption which was first 
described by Duhring and to which have been assigned by different 
authors the titles seborrhcea corporis, seborrhoea papulosa or lichen- 
oides (Crocker), lichen circumscriptus (Willan), lichen annulatus 
et serpiginosus (Wilson), and flannel-rash. Its favorite sites are 
the sternum and interscapular region, but rarely it spreads in more 
extensive areas on other parts of the trunk. In a well-marked case 
the lesions appear in the form of sharply outlined circles or segments 
of circles which enlarge centrifugally, often coalescing to form patches 
with irregularly circinate outlines. The extreme borders, which rep- 
resent the early stage of the lesions, are made up of very small red 
papules, usually covered with fine, whitish or yellowish, dry or fatty 
scales. As the border progresses the centre undergoes involution, so 
that from without inward the patch may display varying shades of 
red, brown, and yellow, while the whole surface is often the seat of a 
furfuraceous desquamation. Round or oval, somewhat elevated, solid 
lesions are frequent, and may scale slightly or be covered with yellow, 
greasy crusts. In less perfectly developed cases and in those modified 
with friction of the clothing or frequent bathing, there may be simply 
yellowish, finely scaling patches with slightly reddened, more or less 
irregular borders. 

The eruption also occurs upon the trunk and extremities in the 
form of macules, papules, and reddened patches which by coalescence 
of individual lesions may become quite large. These lesions may 
present any degree of scaling or crusting, though there is usually a 
narrow, uncovered reddened margin. The affected areas may be dry; 
and in form, distribution, and general appearance closely simulate 
psoriasis ; or they may be somewhat moist and, as a result of irritation 
or of excessive exudation, may undergo a transformation to a condi- 
tion indistinguishable from that of eczema. In most cases the yellow- 
ish color of the lesions is conspicuous, being most marked when the 
eruption is fading. While the dorsal surfaces of the hands and feet 
may be involved it is very doubtful if seborrhoeie dermatitis ever af- 
fects the palms and soles. 

In the axilla and groin the eruption often begins as an erythema 
intertrigo, and owing to the influence of heat, moisture, and friction 
in these regions secreting patches are common. From these points 
the disease often spreads to the adjoining surfaces, the advancing 



PLATE LL 




Photo by Oram. 

Dermatitis Seborrhoiea. (Stopford Taylor.) 



PLATE LII 




Photo by Oram. 

Dermatitis Seborrheica. (Stopford Taylor.) 



BEEMATITI8 SEBOBEHOICA. 901 

margin of the eruption always being sharply outlined and usually 
of circinate contour. 

Etiology. — In his first description of eczema seborrhoi'cum Unna 
claimed for it a parasitic origin. He has described three varieties of 
diplococci which he found in the lesions of this disease, beside several 
varieties of bacilli which were occasionally present. Of these he con- 
sidered a mulberry-shaped coccus, which he called the Morococcus, of 
special importance, and on occasions has produced with it, by the 
inoculation of pure cultures, one or more vesicles, but without repro- 
duction of a patch of true eczema seborrhoi'cum. He also found 
Melassez's flask-shaped bacillus in the scales. 

Elliott 1 reports on a bacteriological study by W. H. Merrill, of 
fifty cases of eczema seborrhoi'cum. In all but two cases, on which a 
solution of resorcin had been freely used, bacteria of some kind were 
found. Merrill describes two varieties of diplococci and a bacillus, 
all three of which were present in thirty-one cases, while one or two of 
them were found in most of the remaining cases. Twelve inocu- 
lation-experiments were made, of which seven were successful ; from 
pure cultures of the cocci typical lesions of the disease were produced, 
from which, in each case, the special coccus was recovered and culti- 
vated. One of these cocci was decided to be chromogenic and the 
cause of the yellowish color characteristic of the disease. These ex- 
periments, though too few in number to be conclusive, would seem, 
when considered in connection with clinical evidence, to leave little 
doubt of the parasitic origin of the disease. The etiological value of 
the micro-bacillus of Unna and Sabouraud is considered in the dis- 
cission of Seborrhoea. Positive evidence of the transmission of the 
disease from one individual to another is difficult to get, though a 
history of probable contagion is obtained frequently. 

Locally, heat, moisture, friction, and other forms of irritation may 
act as predisposing causes and favor the origin and spread of the dis- 
ease. On the body it is often found in those who perspire freely and 
who wear woollen next the skin. On the scalp it is common in 
those who keep the head covered much of the time. Elliott reports 
that most of his cases occurred in people who lived for the most 
part indoors, and that the affection is unusual among those who live 
largely in the open. His explanation of the greater prevalence 
of the disease in winter than in summer is that in the former season 
most people live indoors, with poorer ventilation, and bathe less than 
in summer. 

The systemic conditions favoring the development of the disease 
are practically those named as predisposing causes of seborrhoea. 

Pathology.— Even in the mildest grades of the affection, corre- 
sponding to the condition known as pityriasis capitis, Elliott 2 found 
" slight inflammatory infiltration about the papillary vessels and the 

1 N. Y. Med. Jour., 1895, Mi., p. 528. A subsequent report by Merrill, ibid., 
1897, lxv., p. 322, confirms these findings. 
2 Morrow's System, iii., p. 282. 



902 DI SOU DEBS OF THE APPENDAGES. 

ascending branches from the subpapillary plexus, and along the hair- 
follicles/' while in the rete there were some vacuole-like formations 
in the basal layer, and a few wandering cells. In severer grades the 
inflammatory infiltration extended to the subpapillary plexus, and in 
higher grades to the entire cutis, which was then somewhat (Edema- 
tous. In the rete, vacuoles were numerous and their origin could be 
traced to a nuclear degeneration. Many wandering cells were pres- 
ent, also karyokinetic figures and areas of cell-degeneration. The 
horny layer was thickened and easily detached from the interfollicu- 
lar spaces, but densely packed in the dilated openings and necks of 
the follicles. The sebaceous glands were apparently normal. The 
coil-glands in many instances were dilated and contained cast-off 
epithelial cells mixed with a granular debris, while mitosis and cell- 
degeneration were seen frequently. Elliott found no appearance that 
would warrant him in believing the coil-glands to be the source of 
the fatty hypersecretion. Unna, on the other hand, found fat in the 
coil-glands, and believes them to be the source of most of the fatty 
secretion characteristic of the disease. He also describes an infil- 
tration of small, free globules of fat through all parts of the cutis and 
rete, inside the lymph-sacs. Elliott found no evidences of such infil- 
tration ; but Ledermann announces that he has recognized it in 
normal epithelium. 

Unna and Elliott agree in considering all stages of the process an 
inflammation of a catarrhal nature, the immediate cause of which is 
to be found in one or more specific microorganisms. (See also 
Seborrhoea. ) 

Diagnosis. — From other forms of dermatitis and from simple 
eczema, dermatitis seborrheica may be distinguished by its origin on 
the scalp, its oily secretion and crusts, the yellowish color and sharp 
outline of its lesions, its tendency to spread peripherally in circinate 
outlines, and by its lack of marked subjective sensations. 

In some forms of the disease the diagnosis from psoriasis is diffi- 
cult, but the location of the lesions on the flexor rather than on the 
extensor surfaces, the oily character of the scales and crusts, the yel- 
lowish color, the greasy and scaly centre of circinate lesions undergo- 
ing involution, and the general course of the eruption, will usually 
suffice to distinguish the disease. 

Pityriasis rosea may present appearances similar to those of 
dermatitis seborrhoi'ca of the trunk and extremities. The lesions in 
the former disease, however, do not appear on the scalp, usually have 
ill-defined, frayed-out borders, and the enlarging rings present a dry, 
fawn-colored centre which is free from greasy scales. The affection, 
moreover, runs an acute course, rarely lasting more than six or eight 
weeks. 

Lupus erythematosus occurs chiefly upon the face ; it is rarer upon 
the scalp and body. The scales of lupus are tenacious and dry, and 
require scraping for their removal ; the contour of the lesions is well 
defined, and scars are produced as the condition resolves. Erythema- 



DERMATITIS SEBOBBHOICA. 903 

tous lupus is far less amenable to treatment, and persistency of le- 
sions after a faithful trial of the remedies usually effective for sebor- 
rheic dermatitis should always suggest a reconsideration of diagnosis. 
This fact holds especially true of lesions upon the scalp. 

Tinea circinata often appears upon the face, and might be mis- 
taken for seborrhoic dermatitis ; but the tendency to clear in the 
centre as the margin advances, the distinct elevation of the active edge, 
and the discovery of the fungus will establish the diagnosis. The 
same criteria hold for eczema marginatum, in which the tricho- 
phyton invades the crural region; in this, however, the fading of 
the central portion is less pronounced than in ringworm elsewhere 
and more dependence must be placed on the well-defined, elevated, 
advancing margin, and the demonstration of the organism. 

Treatment. — Sulphur, resorcin, salicylic acid, white precipitate, 
and other preparations of mercury are remedies most useful in the 
treatment of all stages of the disease. For the earlier and dry forms, 
stronger and more stimulating preparations may be used, together 
with more frequent washings of the skin, than in the acute, moist 
forms, which must be treated more in accordance with the principles 
laid down for the treatment of the corresponding stages of eczema. 
For the scalp and other hairy portions of the body lotions are usually 
better than ointments. The lotion recommended by Elliott, contain- 
ing 3 to 20 per cent, of resorcin in equal parts of alcohol and water, 
is one of the best, and should be applied two or three times daily. 
For the dry forms of the disease a small amount of oil — preferably 
the oil of sweet almonds — to prevent the disagreeable drying effect of 
the lotion alone, may be added. Instead of thus combining the oil 
with the liquid, a thin ointment containing resorcin or sulphur may 
be substituted for or applied after the lotion. After soap-and-water 
washings, which should be used often enough to prevent accumulation 
of scales and crusts, an oily or fatty application is always desirable. 

The most serviceable ointment in the majority of cases is one con- 
taining from 1 scruple to 2 drachms (1.33 to 8.) of sublimated or 
precipitated sulphur, 10 minims (0.66) of balsam of Peru, and 1 
ounce (30.) of vaselin. Instead of sulphur, resorcin or white precipi- 
tate may be used. In some chronic cases with much infiltration, sul- 
phur, resorcin, and salicylic acid may with advantage be combined in 
the same ointment, while in a few instances the tars, pyrogallol, or 
chrysarobin may succeed after the above-named preparations have 
failed. In acute forms, in which the symptoms are more those of an 
acute eczema, pastes and ointments containing salicylic or boric acid 
are valuable until the acute inflammatory condition has subsided, 
when preparations containing sulphur or resorcin should be used. 

The disease is usually more amenable to treatment than eczema, 
though recurrences are common. 



904 DISOEDEES OF THE APPENDAGES. 

ASTEATOSIS. 

(Gr., a, privative; areap, fat.) 

(Xerosis. Ger., Asteatose; Fr., Asteatose.) 

Asteatosis is that condition of the skin in which there is absolute 
or relative deficiency of the sebaceous secretion. 

Symptoms. — Insufficient lubrication of the skin by its natural 
unguent may be either general or partial, and occur as an idiopathic 
or a symptomatic disorder. It is produced artificially by any agents 
which continually withdraw the fatty substance from the skin-surface, 
as in those trades necessitating the constant immersion of any part of 
the body in strong alkaline solutions or in waters strongly impreg- 
nated with calcium and potassium salts. As an idiopathic affection 
it is of rare occurrence, but it is not an infrequent accompaniment of 
other local or constitutional diseases, such as psoriasis, lepra, xero- 
derma pigmentosum, ichthyosis, and lichen ruber. In these cases the 
skin becomes dry, often thickened and indurated, and, as a conse- 
quence, friable, and prone to desquamation, fissures, and chaps. To 
the touch, the absence of sebaceous secretion is noticeable in the 
objective sensation produced. Asteatosis is a well-marked feature of 
the marasmus of old age. Some authors have described under this 
title the dry thickening and induration of the palm of the hand accom- 
panied by curving of the fingers toward the plane of their flexor ten- 
dons, a condition that is occasionally to be observed in laundresses. 

Treatment. — Xo internal medicaments are known to have the 
power especially of stimulating the sebaceous secretion. None, in- 
deed, could be capable of having such action when, as is often the case 
in the disorders characterized by asteatosis, there has resulted an 
atrophy of the sebaceous glands. For external application of an 
artificial unguent, cod-liver oil, almond-oil. lanolin, palm-oil, vaselin, 
lard, or butter may be employed. Vaselin is in many cases to be pre- 
ferred, as the other articles named are liable to become rancid after 
oxidation, and thus act as irritants. Elliott prefers liquid albolene 
or benzol. With such partial or general lubrications, however, a warm 
bath of soap and water should be ordered every second or third day ; 
immediately after the bath the inunction may be repeated. 

Prognosis. — In all cases in which the asteatosis is induced by 
agents operating externally upon the surface a reasonable hope of 
recovery may be entertained after withdrawal of the cause. Per- 
sistence of the latter is liable to be succeeded by the occurrence of 
eczema or dermatitis medicamentosa. A complete cure can scarcely 
be expected when this condition is a symptom of one of the disorders 
already named. 



MILIUM. 905 

MILIUM. 

(Lat., milium, a millet-seed.) 

(Grutum, Strophulus Albidus, Tubeeculum Sebaceum, Acne 
Albeda. Fr., Acne miliaike.) 

Symptoms. — Milia occur upon and about the eyelids, the cheeks, 
the forehead, the temples ; the penis, scrotum, and corona glandis of 
men ; and the internal face of the labia minora of women. They are 
millet-seed- to pinhead-sized, pearly-white, occasionally symmetric- 
ally placed, globoid masses, rarely attaining the dimensions of a 
coffee-bean, showing within the epidermis as though portions of 
kernals of rice were lying immediately beneath a translucent layer 
of tissue. They occasionally project from the surface to such an 
extent as to resemble small-sized vesicles having milky contents. 
In color they are yellowish and whitish. They are often congenital, 
and can be recognized about the lids and temples of the newborn in- 
fant ; they are also seen, however, in middle life, when they develop 
very slowly, and sometimes persist for years. They occasion no sub- 
jective sensation, and are commonly so insignificant as to induce no 
deformity. They never degenerate by ulcerative processes, but when 
not artificially removed, in the course of years are exfoliated in the 
natural processes of physiological desquamation. In rare instances 
the deposition within the milia of the salts of lime renders them as 
hard as cartilage (Cutaneous Calculi). They are usually larger than 
the small-sized lesions and of a more yellowish hue. 

Etiology. — Milia may be of embryonic origin and occur in the 
newborn; they are common in infancy and early adult life, and are 
rare in middle life, though occasionally developing after the thirtieth 
year. They are at times produced mechanically ; the stroke of a knife- 
blade, accidentally or in the processes of surgery, separating one or 
more of the acini of a sebaceous gland from the main body. The con r 
tracting bands of a cicatrix, after destruction of tissue from any 
cause, may operate in a similar way with precisely the same result, 
and they may thus follow the lesions of tuberculosis, syphilis, ery- 
sipelas, and pemphigus vegetans. 

Pathology. — When a milium is incised externally a spherical body 
of nearly corresponding size may be expressed, though it may require 
tearing from a minute pedicle below, which represents the attachment 
to the hair-follicle. The small mass thus extracted is seen to be a 
horny cyst composed of several thin envelopes, suggesting the cap- 
sules of the onion and representing cornified epithelia which have not 
undergone fatty metamorphosis, and in the centre of which is a fatty 
nucleus. There is never any lobular formation. Each of these horny 
cysts is developed in connection with the lanugo hair-follicles, dis- 
tending the latter, as Unna has shown, irregularly and on one side. 
The process represents a hyperkeratosis of the epithelium of the hair- 
follicles, though it is believed by some that the milium represents a 
retention-product of the sebaceous glands. 



906 DISORDERS OF THE APPENDAGES. 

The epithelia from which the contents of milia are produced at 
times tend to develop into other than horny formations. Thus, Fos- 
ter, of Boston, describes a case in which the process of calcification 
had apparently been complete; Wagner observed colloid contents in 
certain opalescent lesions which appeared on the cheeks and temples 
of a woman. Virchow and Rindfleisch describe milia of the hair- 
sacs and similar lesions accompanied by cysts of the adjacent hair- 
follicles. In some cases the cause of milia is to be sought in obscure 
changes by which the epithelia of the follicle are primarily affected. 
Robinson believes that milia originate from miscarried embryonic 
epithelia from hair-follicles or from the mucous layer of the epi- 
dermis. 

Diagnosis. — Milia might be mistaken for minute vesicles contain- 
ing a milky fluid, but puncture of the lesion, with expulsion of its 
contents, at once discloses their character. Comedones with blackish 
external points, surrounded by the patulous orifice of the excretory 
duct and prolonged more deeply into the substance of the skin, could 
scarcely be confounded with milia. 

The most minute of the lesions of xanthoma have a yellowish color, 
and cannot so readily be scraped away from the subjacent tissue as 
can milia. 

Treatment. — Milia rarely require treatment, as they are usually 
relatively few in number, and produce neither subjective sensation 
nor deformity. If desired, they may be opened with a fine milium- 
needle and their contents turned out, or they may be scraped off with 
a curette. To insure their non-recurrence, the little sac left after the 
operation may be entered with a needle which has been dipped in a 50 
per cent, solution of chromic acid. This operation may have to be 
repeated in the rare cases in which the lesions exhibit a tendency 
to recur. 

The convenient method of removing these and many similar-sized 
lesions of the skin is by electrolysis. With from four to six cells in 
the circuit the negative pole is connected with a fine needle, which is 
introduced within and beneath the lesion, while the moistened sponge 
of the positive pole i$ in contact with the skin of the patient. This 
operation is bloodless and effectual, insignificant scars resulting. 

Occasionally milia upon the scrotum give rise to sexual hypo- 
chondriasis which may demand attention; suggestive rather than 
active operative treatment is needed in these cases. 

Prognosis. — The prognosis is always favorable. 

Milium Congenitale (en plaques) has been described by Crocker, 1 
Hans Hebra, Wilson, and Fox, as a congenital condition in which oc- 
curs a reddish-yellow patch (destitute of hair when existing on the 
scalp) with well-defined border and a granular surface, constituted 
of minute yellowish papules, with comedones at the periphery and 
elsewhere. 

1 Diseases of the Skin, 3d ed., p. 1131. 



STEATOMA. 907 

Hypertrophy of the Sebaceous Glands, characterized by actual mul- 
tiplication of the glandular acini, is described by Crocker 1 as of oc- 
currence on the forehead, nose, and other parts of the face of the 
aged, often accompanied by minute disks of a light-yellowish or 
dirty-yellowish shade, having a central punctum corresponding to the 
opening of the duct. In other cases discrete nodules occur. The 
author cited has noted their concurrence with jaundice and general 
xanthoma. In one case pinhead- to hemp-seed-sized, opaque and 
sometimes superficially vascularized papules with depressed centres 
formed ; the smaller were semitranslucent ; some contained a central 
plug that could not be expressed. 

We have observed this condition in two middle-aged women in 
good health. The lesions in both instances were scattered singly or 
in groups of three or four over the face. Some of the lesions sug- 
gested strongly those of molluscum contagiosum. In some the disk 
was apparently made up of three or four pin-head-sized lobules co- 
alescing about a depressed follicular opening which was not always 
centrally situated. We have seen the condition also preceding the 
development of superficial epithelioma, and also when existing on the 
face with development of similar lesions upon the backs of the hands 
distinctly epitheliomatous in type. 

Pollitzer 2 reports a case of this type in which the lesions were 
arranged in a double row, about an inch and a half long, on the fore- 
head above the left eyebrow. As the result of histological examina- 
tion, Pollitzer reported the case as one of adenoma sebaceum, although 
clinically it did not correspond to the cases usually included under 
that title. On the other hand, Marrullo, 3 Whitfield, 4 and others find 
that the cases which clinically are known as adenoma sebaceum, show 
histologically an hypertrophy and not the structure of adenoma. 

STEATOMA. 

(Or., areaf), fat.) 

(Wen, Atheroma, Pseudo-atheboma, Sebaceous Cysts, Sebace- 
ous Tumoe. Fr., Steatome, Kyste sebacee; Ger., Balgge- 
schwuist, Geutzbeutel. ) 

Symptoms. — The history of the development and career of wens 
does not greatly differ from that of milia. Wens are usually of slow 
growth; unattended by subjective sensation; occur as single or mul- 
tiple, elevated, occasionally flattened, fixed or movable tumors on the 
head, the trunk, or the genitals; and, being larger than milia, may 
attain the size of a hen's egg. Centrally or laterally placed is seen 
usually on the surface of each a patulous orifice closed with a black- 

1 Ibid., p. 1131. 

2 J. C. I)., 1893, xi., p. 475 (with clinical and histological illustrations) . 

3 Zeitschrif t, 1902, ix., p. 166 (with bibliography) . 
i B. J. D., 1902, xiv., p. 326. 



908 DISOBDERS OF THE APPENDAGES. 

ened horny plug suggesting a giant-comedo. They are situated be- 
neath, within, or upon the skin ; usually are unattached to the deeper 
contiguous tissues; and develop into irregularly globular, occasion- 
ally targe button-shaped masses, covered by an integument usually 
unprovided with hairs. This envelope may be normal in hue, or un- 
naturally whitish from pressure; or, especially upon the bald scalp 
of certain fleshy men of middle years, reddened, shining, and greasy 
in appearance. Their semisolid cheesy and milky contents often emit 
a nauseous odor. At times the cysts are to be distinguished only by 
passing the fingers through the long hairs of the scalp beneath which 
they are hidden; at other times they are so conspicuous in conse- 
quence of physiological alopecia as to occasion considerable disfigure- 
ment. They vary greatly in consistence, but usually produce to the 
touch a certain feeling of elasticity, especially if the cyst be distended 
tensely. They may persist for years without producing inconvenience 
save that resulting from their bulk and the consequent disfigurement, 
but may be attacked by inflammation, resulting in suppuration and 
ulceration. 

Cysts {Sudoriparous Fat-cysts [Dubreuilh]) of the steatoma type 
may be single or multiple and numerous. Maclaren 1 reports the case 
of a lad, nineteen years of age, having tumors of this sort over the 
entire body-surface ; they resembled fibromata, but were found on 
examination to be sebaceous in character. Dubreuilh, Auche, and 
Chiari have reported similar cases in which pin-head- to pea-sized, 
firm, well-rounded lesions, subcutaneous in situation, but at times 
projected from the surface, had either the color of normal skin or 
were grayish-yellow in hue, occurring about the axillse, the scalp, the 
extremities, or generally over the trunk. They contained a semifluid 
material, and were found to be thin-walled cysts with a tenuous en- 
velope, epithelium-lined, derived originally from the coil-glands. We 
have had under observation a young woman the upper part of whose 
chest was covered thickly with pin-head-sized and somewhat larger 
retention-cysts covered with normal skin, the contents of which were 
wholly sebaceous. 

Chalazion is a term descriptive of pin-head- to small-nut-sized 
tumors occurring in relation with the Meibomian follicles. They 
were thought once to be of sebaceous origin, but are now recognized as 
benignant new growths. A fungus supposed to be pathogenic has 
been recognized by Weyman. 

Pathology. — Wens represent distention of the sebaceous glands 
by their contents, and response to the constant pressure in hyper- 
trophy of the glandular envelope. Their contents, which are semi- 
solid, curdy, cheesy, and granular, fluid and milky, or fluid and puru- 
lent, are the inspissated or chemically altered products of the gland- 
secretion, recognizable as such by the materials of which they are 
composed — masses of fat and debris of epithelia, with an occasional 
lanugo- or undeveloped hair. 

1 Brit. Med. Jour., October, 1886. 



STEATOMA. 909 

In some cases wens are more than mere retention-cysts, a benign 
new-growth of connective tissue forming the mass of the tumor. 
Calcareous and atheromatous changes in the contents of the cyst are 
common. Torok, Chiari, and others claim that the majority of these 
growths are really dermoid cysts. Torok 1 found a true papillary body 
in the walls of many of these cysts, and states, furthermore, that such 
cysts contained no fat. Ehrman and Fick 2 suggest that the patho- 
genesis may be explained by anomalies in the life-history of the cells 
of the sebaceous glands whereby they undergo horny rather than fatty 
metamorphosis, thus leading to retention and cyst-formation. 

Diagnosis. — Steatomata are to be distinguished from true athero- 
mata in that the latter exhibit no opening, never have odorous con- 
tents, always originate in the hypoderm, and frequently occur in 
portions of the skin other than the scalp. Steatomata are also to be 
distinguished from fatty tumors, which, however, are observed more 
commonly about the scapula?, loins, buttocks, and extremities; while 
wens are very rarely found except about the scalp and neck ; they lack 
also the peculiar " pillowy " feel of fatty tumors. Suppurating wens 
in the regions named may readily be mistaken for circumscribed 
abscesses if regard be not had for the history of the tumor usually 
long preceding. Syphilitic nodes and gummata of the same parts are 
usually both tender and painful; osteomata also are attached firmly. 

Treatment. — The removal of a wen is accomplished by excision, 
after previous puncture of the sac and removal of its contents. 

With antiseptic precautions ablation of these lesions from any 
part of the body may be regarded as unattended with great risk. 
Several fatal cases, however, are on record as the result of this opera- 
tion, due not so much to the nature of the excised tumor as to its 
situation, surgical wounds of the scalp being particularly liable to 
erysipelatous and other complications. As the incision required for 
the removal of the wen necessarily must extend some distance on 
either side of the tumor, there results a linear scar, which on the bald 
scalp is often a very conspicuous relic of the lesion. In consequence 
of the possibility of danger many surgeons prefer destruction of a 
prominent section of the mass with acid or alkali, leaving the sac, 
after expulsion of its contents, to wither gradually, though it may then 
often be withdrawn with forceps. 

Complete obliteration is sometimes effected by puncture, expres- 
sion of the contents, and subsequent induction of artificial inflamma- 
tion in the walls of the cyst by injection of tincture of iodine, pure 
sulphuric ether, or other irritating fluid, as in the operation for relief 
of hydrocele. 

Prognosis. — The removal of the wall of the cyst is not followed 
by a return of the lesion. In debilitated and cachectic patients there 
may be spontaneous ulceration and sloughing, with or without sur- 

1 Monatshefte, 1891, xii., p. 437. 

2 Kompendium der Speziellen Histopathologic der Haut, Wien, 1906. 



10 



DISORDERS OF THE APPENDAGES. 



gical interference. Mr. Thomas Bryant 1 reports a carcinomatous 
tumor following the removal of a steatoma from the buttock of a 
woman sixty-three years of age. 

Congenital Fibro-sebaceous Disease.- — Crocker reports two instances 
occurring in infants who at birth exhibited signs of the disease, in 
which patches with an area of " several square inches " were visible 
on the face, the front of the neck, and in front of and above the ear. 
These patches were slightly raised, of a pale reddish-yellow color, 
finely granular over the surface, and consisted of closely aggregated, 
pale-yellowish, pin-point-sized papules, the patches being sharply de- 
fined with many comedones at the borders. These growths, on sec- 
tion, seemed to be due to a fibrous hypertrophy resulting in atrophy 
of the hair-follicles and coil-glands, and separation of the lobes of the 
sebaceous glands. 

Sebaceous Cystic Disease is reported by Cook, Hutchinson, and 
others, in cases in which steatomata in typical situations resulted in 

Fig. 184. 




Multiple sebaceous cysts of the scrotum. 



ulcerations of malignant type ; in still other cases fungous tumors of 
considerable size formed, requiring surgical attention. 
1 B. M. J., 1884, i., p. 1044. 



COMEDO. 911 

COMEDO. 

(Lat., comedo, spendthrift.) 

(Black-head. Ger., Mitesser; Fr., Acne poncttjee, Acne 

COMEDON.) 

Symptoms. — Comedones are grayish, blackish, yellowish, or other- 
wise colored, dots or points, resembling grains of powder sprinkled 
over the surface of the skin, each point representing the external ex- 
tremity of a ping of inspissated secretion lodged in the excretory duct 
of a sebaceous gland. Occasionally the comedones project to an ap- 
preciable distance above the general level of the integument, but 
often the extremity of each plug is slightly depressed below that 
level. There may be but two or three comedones upon the face, which 
is their commonest seat ; or the nose, forehead, cheeks, and chin, the 
front and back of the neck, the concha of the ear, the back of the 
trunk, and the penis may be studded with them thickly. They may 
also be found upon the hairy scalp. The visible extremity of the 
comedo varies in size from that of a needle-point to that of a pinhead. 
Comedones are readily expressed from the follicles in which they are 
lodged, and when thus examined they are seen to be whitish moulds 
of inspissated sebum, one or two lines in length, the exposed extremity 
of each comedone having become discolored by diffused pigment de- 
posited within. In consequence of this suggestive appearance of the 
lesion the disease has been called vulgarly " black-heads " and " skin- 
worms." The deformity produced in the face when these lesions 
exist there in large numbers is strikingly conspicuous, and it is for 
the relief of this appearance chiefly that the practitioner is consulted. 
The subjective symptoms awakened are of trifling moment. The dis- 
order is essentially chronic in its course. Isolated comedones may be 
observed for years in one situation without apparent change or modi- 
fication of any sort, and without producing the slightest local or 
constitutional derangement. Others appear, only to disappear under 
the influence of the usual hygienic regimen of the skin of the face. 
Others, again, serve to irritate the skin in which they are implanted; 
precisely as though they were foreign bodies ; and the sebaceous glands 
and periglandular tissues, with and without the operation of such 
cause, exhibit grades of hypersemia and inflammation, the lesions be- 
coming those of acne. Comedones occur as the sole lesions of the 
skin, even to the extent of great multiplicity ; more frequently they 
coexist with other diseases of the sebaceous glands, chiefly acne and 
oily seborrhcea. 

Occasionally a so-called Double Comedo is found. When ex- 
pressed from the skin the plug of inspissated sebum is seen to have 
both extremities discolored. Grouped comedones, first described 
by Thin 1 are commonly found in symmetrical disposition on the 

1 Lancet, 1888, ii., p. 712. 



912 DISOKDEBS OF THE APPENDAGES. 

cheeks, but may occur upon the back and chest, as reported by Little 1 
and MacLeod. 2 They usually do not coexist with other lesions of 
acne vulgaris. Scar-comedones, single, double, and grouped, have 
been recognized in the form of atrophy of the follicular orifice (Lang, 
Selhorst, Thibierge). Large and numerous lesions of this type have 
been reported after kerion (Crocker), and variola (de Coquet). 

Etiology. — Comedones may occur at any period of life, but, like 
seborrhoea, are most frequently observed at the puberal epoch in both 
sexes, when the pilo-sebaceous structures take on a greatly increased 
activity. They may occur in children, with a special tendency to 
grouping in places subjected to heat and moisture. Eecently we have 
recognized them in typical development and considerable number on 
the face of a nursing infant. Crocker was first to notice the fact of 
their occurrence in young subjects. Much has been written with ref- 
erence to neglect of the skin as a cause of comedo, the non-employment 
of soap in washing the face, and the influence of the trades, as in the 
case of those who work in metals, dust, and tar ; but observation shows 
that these are rather exceptional causes. On the one hand, very 
obstinate and generalized lesions occur in the skin of intelligent young 
men and women of the upper social classes, who regularly wash their 
faces with toilet-soap, who are rarely exposed to dust, and whose 
habits and recreations are of the most healthful character. On the 
other hand, observing the grimy faces of coalheavers, machinists, 
masons, and ink-manufacturers, one is impressed with the rarity of 
the disease in such laborers. Other causes of the constipation of the 
gland are unquestionably effective in most cases. This disorder is 
somewhat more frequent in thick-skinned brunettes, or in men with 
a characteristic reddish-brown and greasy-looking complexion than in 
individuals having a fair and delicate skin. 

In many patients there is unmistakable connection between this 
disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation 
of the bowels, menstrual derangements, and cachexia. This connec- 
tion is demonstrated by the remarkable improvement manifested in 
the untreated skin when restoration of the general health is assured. 

The microbacillns of I una and Sabouraud may be found, as a 
rule, in the comedo-plug, but whether the bacillus causes or follows 
the formation of the comedo is an unsettled question. (See chapter 
on Seborrhoea.) Acarus folliculorum (see paragraphs under this 
title) is also found in the comedo, but plays no part in the etiology 
of the disorder. The grouped comedones are believed to be due to 
some form of local infection the exact nature of which is not de- 
termined. 

Pathology. — Comedo is a dense collection of concentrically ar- 
ranged epithelial cells, in the centre of which are dried sebum, frag- 
ments of epithelia that have undergone partial fatty transformation, 
and minute lanugo hairs. It is located either in the excretory duct of 

1 B. J. D., 1903, xv., p. 253. 

2 B. J. D., 1903, xv., p. 453. 



COMEDO. 



913 



the sebaceous gland, or in the pouch-shaped canal common to the se- 
baceous gland and the hair-follicle. The first step in its formation 
is hyperkeratosis of the duct produced by some external irritation. 
In the regions in which comedones are found the sebaceous glands are 



Fig. 185. 




Section of a comedo : a, excretory duct of a sebaceous gland filled with a comedo ; it 
contains also two small hairs with brush-like inferior extremities ; into it opens a small 
hair-follicle (c) ; the contained hair (d), after touching the opposite wall of the duct, 
curves downward at f. (After Kaposi.) 



much larger than the hair-follicles to which they are attached. In 
consequence, as demonstrated by Biesiadeeki, the hair-follicles often 
form obtuse or even right angles with the duct of the gland, causing 
the point of the hair to project against and irritate the wall of the 
duct. Unna, Sabouraud, and others believe the external irritation 
is furnished by a definite microorganism (see Seborrhoea), Sabou- 
raud claiming that comedo is always preceded by oily seborrhcEa. 
The blackness of the head of a comedo may be due in part to accumu- 
lation of dust or dirt, but is owing chiefly to a definite pigment which 
extends for some distance below the exterior face of the plug. This 
pigment is soluble in concentrated nitric or hydrochloric acid, and in 
hydrogen peroxide. The double comedo is believed to arise from the 
merging of two glands in close proximity by pressure atrophy of the 
tissues which normally separate them ; thus one cavity with two ducts 
would be formed. 
58 



914 DISORDERS OF THE APPENDAGES. 

Diagnosis.- — The recognition of the disorder is attended with no 
difficulty, patients themselves being usually sufficiently observant to 
identify the affection, though frequently misled as to the character of 
the " skin-worm." It is, as might be expected, a frequent coincident 
of acne ; its lesions, when commingled with those of the disease last 
named, being either in preponderance or so infrequent as scarcely to 
attract the attention of the patient. A condition somewhat resembling 
comedo may be produced upon the face when tar or ointments of 
mercury and sulphur are applied to it at the same time, the resulting 
black sulphuret appearing conspicuously at various, points upon the 
skin, often at the orifices of the sebaceous glands. 

Treatment. — The internal treatment of patients affected with 
comedo is that described in connection with the subject of Seborrhcea. 
Cod-liver oil, iron, the bitter tonics, and the medicaments indicated 
by any special condition of the patient's health are not to be omitted. 
Open-air exercise, daily cool salt-and-water bathing, as in the man- 
agement of seborrhcea, and the avoidance of all medicinal and dietary 
articles which might tend to aggravate the disorder, are also impera- 
tive. Many of these patients require at the outset alterative cathar- 
tics, among which may be named the pill of blue mass (taken for 
several consecutive evenings, and followed by the effervescing sodium 
phosphate in the morning), calomel, cascara sagrada, and castor-oil. 

Even aggravated cases of comedo are completely relieved when 
untreated in the course of time. The relief, however, may require 
years for completion. The rarity of comedones in middle life and 
advanced years sufficiently attests this fact. Presumably this natural 
cure is due to the removal of irritation within the duct in consequence 
of a more vigorous growth of lanugo-hairs with the increment of age. 
Absence of comedones from the scalp, with a few marked exceptions, 
where the hair is vigorous, is certainly a significant fact. 

Comedones are removed artificially with the aid of an extractor. 
The instrument formerly employed for this purpose was shaped like 
a watch-key, the cylinder having a smooth bore and bevelled ex- 
tremity. This clumsy tool is far surpassed by the exceedingly con- 
venient comedo-extractor designed by Unna and modified by Piffard. 
Each end has a convex, bowl-like surface, with apertures cut to gauge 
and the orifices slightly countersunk. This extractor, or " presser," 
is productive of far less pain to the patient than other instruments, 
and can be wielded, on account of its long shank, with greater pre- 
cision and ease by the physician. The surface to be operated upon is 
previously moistened by spraying it with a solution of formalin (0.5 
per cent.), of thymol and glycerin, or of eucalyptol and glycerin. 
Often a sharp-edged or well-rounded needle, firmly held in a needle- 
holder, may advantageously be employed alternately with the ex- 
tractor, in opening certain follicles or loosening the plug of others. 
Many patients affected with comedo are advantageously treated by the 
aid of the massering-ball, described in the chapter on the management 



COMEDO. 915 

of Acne. All these instruments should be disinfected scrupulously 
before use. The danger of such manipulations should never be over- 
looked. There are many advantages in selecting the hour before sleep 
as the time for all vigorous topical applications to the face. Oint- 
ments then applied can be left in contact with the skin during the 
night and the patient be at liberty to resume his usual vocation in 
the daytime, his face being free from conspicuous evidences of local 
treatment. 

Once the comedones are removed the skin should be sponged and 
bathed with hot water, then thoroughly dried, and anointed with an 
ointment which may be medicated to suit the indications of each case. 
Sulphur, as in many disorders of the sebaceous glands, enjoys here a 
high reputation. In the strength of 10 grains (0.66) to 1 drachm 
(4.) to the ounce (30.) of cold cream or vaselin, it may be applied as ' 
an ointment; or as a lotion, in combination with spirit of wine, gly- 
cerin, etc. A useful application is suggested by Piffard — equal parts 
of sublimed sulphur, alcohol, compound tincture of lavender, glycerin, 
and camphor-water. 

Mercurials are also of some advantage locally, but should not be 
employed at the same time with preparations of sulphur. The use at 
night, especially in obstinate cases, of the white-precipitate ointment, 
or of one compounded of 2 grains (0.133) of the red oxide to the 
ounce (30.) of cold-cream salve, will often prove of benefit. In the 
case of coarser skins, corrosive sublimate, 1 to 2 grains (0.066— 
0.133) to the ounce (30.) of glycerin and rose-water, may be substi- 
tuted for the red-oxide ointment. 

When extraction of the plug is not attempted nor permitted, some- 
thing may yet be done to remove the inspissated mass. Repeated 
sponging every third night with 1 ounce (30.) of green soap, digested 
in an equal quantity of cologne-water, will at first seem to render the 
comedo more conspicuous, but will slowly operate to dissolve the se- 
baceous secretion. 

An ointment containing 4 parts of kaolin, 3 of glycerin, and 2 
of acetic acid, with or without the addition of a small quantity of 
ethereal oil, may be applied at night for a few nights in succession, 
the eyes being carefully protected, when the black points of the le- 
sions are removed, and the comedones are then readily extracted. 
Citric or dilute hydrochloric acid is employed with the same end in 
view. These topical remedies cannot be considered as efficient in 
every form of comedo. 

Comedones of the penis need not be treated. This injunction is 
suggested by the occasional demand made upon the physician by the 
sexual hypochondriac, who regards these lesions with singular alarm. 

Prognosis. — As the disease naturally tends to spontaneous though 
occasionally long-deferred resolution the prognosis is favorable. 
Treatment in most cases will accomplish much in hastening the dis- 
appearance of the comedones. The most obstinate forms are those in 



916 DISORDERS OF THE APPENDAGES. 

which the face, the back of the ears, the inside of the auricle, the 
neck, and the shoujders are studded with relatively small indolent 
comedo-points, about which the circular lip of the duct rises in a whit- 
ish rim. Such cases, however, are nearly allied to the forms of acne 
described elsewhere. With exceeding rarity, the comedo is merely 
the introduction to a more serious local affection. In early life a 
single prominent lesion is formed, and though the plug be frequently 
removed and finally be no longer reproduced, the orifice of the duct 
remains patulous in middle life. Slowly thereafter its walls undergo 
a metamorphosis and a warty epithelioma may result. 

ACNE. 

(Gr., d/av/, a point.) 

(Acne Vulgaris, Varus. Fr., Acne; Ger., Hautfinne, Akne.) 

Acne is a chronic inflammatory disease of the sebaceous glands 
and periglandular tissues, exhibited chiefly over the face, neck, shoul- 
ders, and anterior and posterior surfaces of the upper thorax, in the 
form of an eruption of papules, pustules, and smaller and larger no- 
dules, usually intermingled with comedones, and often associated with 
seborrhcea of the scalp. It rarely develops before the puberal epoch, 
and is unusual after the third decade of life. 

Symptoms. — The disease is characterized in general by the occur- 
rence of several and usually numerous, light-red, dull-crimson, or 
violaceous, pinhead- to small-nut-sized, ill-defined papules, pustules, 
nodules, tubercles, or non-projecting indurations of the skin, often 
commingled with the symptoms of comedo and seborrhcea sicca. The 
lesions are isolated or irregularly scattered over the surface, which, 
however thickly studded with them, never displays a grouping or 
definite arrangement of the elements of the eruption. Many of the 
lesions are both slightly painful and tender, though upon this point 
there is a wide range of difference in various individuals. As a rule 
pruritic sensations are absent. The inflammatory process, which 
manifestly involves the sebaceous glands and periglandular tissues, 
may result in suppuration of several adjacent follicles, as a conse- 
quence of which coalescence occurs and pea- to large-nut-sized cuta- 
neous and subcutaneous abscesses may form. In many cases, how- 
ever, the suppuration is limited to the area of the individual nodule. 
Every feature of the disease, from the smallest papule to the largest 
subcutaneous abscess, may be displayed at the same moment in an 
affected individual. Under circumstances of special aggravation the 
disease may occur in acute forms, but it is commonly chronic, the 
acute phases being usually accidents of the general process. When 
resolution occurs the points of location of former papules and nodules 
are frequently marked by reddish-brown pigment spots which grad- 
ually fade with time. In aggravated cases in which suppuration has 
been extensive small pitted scars are left after the disappearance of 
the disease. 



ACNE. 917 

The lesions of acne are found most commonly upon the face, but 
they are seen frequently upon the neck, the shoulders, the back, and 
front of the upper chest, the genitals, and the extremities, and occa- 
sionally on other parts of the body, the palms and soles being excepted. 
The disease is intermittent in severity, the patient being at times rela- 
tively free from symptoms and at others conspicuously disfigured. 
It is frequently associated with mild or severe alopecia furfuracea and 
seborrhoea capitis, the totality of symptoms depending upon similar 
causes in the susceptible subject. 

In acne certain clinical forms are recognized; these are conven- 
iently designated by various terms which refer chiefly to external 
features. 

Acne Punctata. — In this variety the apex of the developing papule 
exhibits the characteristic blackish punctum of the comedo about 
which the papule is forming. 

Acne Papulosa. — In acne papulosa the lesions are of papular 
type, ranging in size from that of a millet-seed to that of a coffee- 
bean, whitish or reddish in color, and varying in the amount of in- 
duration at the base. They are often commingled with pustules, pap- 
ulo-pustules, and comedones. At the apex of each papule may fre- 
quently be distinguished the blackish point characteristic of acne 
punctata, or a minute, greasy, yellowish-white spot, which represents 
the non-pigmented extremity of an inspissated sebaceous plug. 

Acute Indurata— This type of the disease takes its name from the 
dominant clinical feature and is characterized by the preponderance 
of deeply seated firmly indurated lesions. These have their begin- 
ning in the lower portion of the corium and in the subcutaneous tis- 
sue, develop toward the surface, and eventually appear as conical or 
rounded projections, of variable size and elevation above the normal 
skin. Their color ranges from a light red in the smaller to a dark 
red or violaceous hue in the larger lesions. In severe cases tenderness 
and pain are marked, and the presence of the livid swellings scat- 
tered over the face produces considerable deformity of feature. In 
the larger nodules suppuration occurs, manifested by fluctuation over 
the central portion, the base remaining indurated. Owing to the 
thickness of the roof wall the pus is seldom spontaneously evacuated. 
During resolution which occurs by slow absorption a collarette of 
scales is usually present about the lesion. 

Acne Pustulosa. — This is the most frequently observed of the 
expressions of the disease. The lesions are apt to be commingled 
with papules, comedones, and intermediate phases between the func- 
tional and inflammatory disorders of the glands. The pustules 
almost invariably originate in previously formed papules and may be 
large or be small, containing merely a droplet of pure pus, or, when 
a true furunculosis ensues, a teaspoonful or more of pus may be 
mingled with blood and serum. This accumulation may be evacu- 
ated surgically or accidentally, or be absorbed, or may remain for a 
long period of time in a species of cyst, whence it can finally be 



918 



DISOEDESS OF THE APPENDAGES. 



expressed. In aggravated cases two or more of these pustulo-furunc- 
ular depots may coalesce, forming nut-sized abscesses, or, not rarely, 
may become united by fistulous tracts, through which there is free 
communication of the fluid contents of two or more chambers. 

Acne Vulgaris is a term applied to the composite eruption which 
is common to the majority of clinical cases. Here the various lesions 
described above (papules, pustules, comedones, etc.) are associated, 
usually on the face and over the shoulders, each in several degrees of 
development, often in conjunction with the scars left by a prior 
eruption. Acne Disseminata is another name given by some authors 
to this common composite type of the disease. 

Acne Artificialis. — Various substances, either applied topically to 
the skin or ingested, are capable of producing acneiform lesions. 
Among them may be named tar, which may prove an irritant whether 

Fig. 186. 




Copyright 1900 by G. H. Fox. 

Acne vulgaris. (From G. H. Fox's Atlas of Skin Diseases.) 



employed externally or internally, and, far more frequently, the salts 
of iodine and bromine after ingestion. Tar-acne occurs both among 
workers in tar and in those subjected to the action of this substance 
for the relief of other cutaneous disease. Pinhead- to pea-sized, 



ACNE. 



919 



reddish-brown papules then form, at the apex of each of which is 
perceptible a minute blackish punctum, produced by the lodgment 
of a particle of the medicament in the orifice of a sebaceous follicle. 
Pustular and furuncular lesions are, however, also produced, such as 
occur in bromic and iodic acne. In the latter disease the presence 
of the drug has been demonstrated in the contents of the pustular 
lesions. Chrysarobin and a number of other medicinal substances 
are capable of exerting a like effect. 

Acne Atrophica and Acne Hypertrophica are terms employed to desig- 
nate merely the lesion-relics of the disease. In acne atrophica there 



Fig. 187. 




Scars following acne vulgaris (untreated). 

is complete atrophy of the gland-tissue, indicated by a minute sunken 
pit in the site of the former orifice. In acne hypertrophica there 
are, in consequence of the periglandular exudation, a thickening 
of the tissues about the acini, and a projection from the surface in the 
form of persistent pea-sized, and indurated masses. 

Acne Cachecticorum or Scrofulosorum includes the symptoms en- 
countered in the subjects of struma, scorbutus, marasmus, chloro- 



920 DISOBDEES OF THE APPENDAGES. 

anaemia, and tuberculosis. The lesions are developed more often 
on the trunk and the extremities than over the face, and are indolent, 
papulo-pustules, pinhead- to bean-sized, remarkable for their livid, 
purplish, lurid-red, or violaceous tint. The lesions rarely are indu- 
rated ; more often they are softish, pus- and blood-containing nodules, 
sluggish of career, leaving minute cicatrices. Their features are due 
to the general cachectic condition of the subjects in whom they occur. 
Colcott Fox describes acne scrofulosorum as it occurs in infants. 1 

Keloid-acne (see Dermatitis Papillaris CapilUtii) is a name which 
has been given to an inflammatory folliculitis and perifolliculitis, 
leaving deep hypertrophic scars, usually in the thick epidermis over 
the neck and the back of the trunk, though seen also upon the scalp 
and face. Wisps of thick, distorted, and evidently altered hairs pro- 
ject here and there from the affected surface. Reddish, and even 
vascularized nodes, tubercles, and bridges occur at intervals, inter- 
spersed with occasional acne-pustules and deep-seated, broad, even 
gigantic comedones. Sclerotic tissue, in brief, forms about the site 
of the acne-process quite like cicatricial keloid of the trunk and other 
situations. 

Acne Keratosa is the Acne cornee of French authors. In this 
affection cornified masses of sebum distend and project from the ori- 
fices of the sebaceous glands, particularly over the neck, but also over 
the face, the trunk, the elbows, the knees, and other portions of the 
body. There is some doubt whether this disease should be classed 
with ichthyosis, which it unquestionably resembles, or with keratosis 
pilaris. By some French authors the condition is considered an 
early stage of keratosis (psorospermosis) follicularis. 

Under this title Crocker 2 reports four cases in women in whom 
there appeared on the face, chiefly about the angles of the mouth, 
firm, painful, inflammatory papules, succeeded by pustules and crusts. 
From the centre of these lesions could be expressed short, soft or 
horny plugs which were formed evidently in the sebaceous glands or 
hair-follicles. On removing the plug the lesions healed slowly, in 
many instances leaving a scar. The disease was persistent, lasting 
in one case for forty years. 

Acne Urticata is described by Kaposi, Touton, Lowenbach, 3 and 
others, as occurring on the scalp, face, and other portions of the body. 
The primary lesion, which is preceded by itching and burning, is a 
small wheal which enlarges to the size of from 6 to 12 mm. the 
centre then becomes paler and depressed and shows a vesicle which 
dries into a crust. The crust falls, leaving a small scar which in 
time becomes depressed and shining white. The full development 
of a wheal requires from four to six days. The later stages of the 
process suggest acne necrotica both clinically and histologically. 

Etiology. — Acne is probably the cutaneous disease of most com- 

1 B. J. D., 1895, vii., p. 341. 
2B. J. D.. 1899, xi., p. 1. 
3 Archiv, 1899, xlix., p. 29. 



PLATE LIU 




Aene-keloid of the Back. 



ACNE. 921 

mon occurrence not excepting eczema. Its causes are numerous and 
in many cases obscure. They are both systemic and local, for even 
the most ardent advocates of the parasitic origin of the disease must 
admit that predisposition, based on constitutional conditions, is an 
important factor. The disease occurs usually in the second, and in 
most instances disappears during the third decade of life, although it 
occasionally persists or even begins later. Among the predisposing 
causes the changes incident to the age of puberty in both sexes are 
important. The great physiological activity manifest in the hair- 
follicles and sebaceous glands at this period of life is easily perverted 
to the pathologic by such frequently operative factors among young 
people as illness, malnutrition, overwork, or improper conditions of 
life. 

The disease very often is related to disturbances of the gastro- 
intestinal tract 1 especially constipation, hepatic torpor, and fermenta- 
tive dyspepsia. The eating of indigestible food, overindulgence in 
alcohol, coffee, or tobacco, as well as overeating, frequently cause an 
outbreak of lesions in the predisposed individual. In the matter of 
diet individual peculiarities are evident; articles of food which are 
perfectly well borne by one may provoke an attack of acne in another. 
Certain drugs, more commonly the bromides and iodides, aggravate 
an existing acne. In women the disorder is frequently worse just 
before or during the menstrual period. At times reflex nervous in- 
fluences seem to stand in causal relation to the disease. It must be 
said, however, that in many individuals suffering from acne no defect 
in the general health can be discovered. 

In some cases the disorder is limited for long periods of time to 
a few follicles or to a small area, and is undoubtedly local in origin. 
Among the local conditions favoring the development of acne may 
be mentioned ; oiliness of the skin due to hyperactivity of the sebaceous 
glands; mechanical plugging of the sebaceous follicles, as with dust 
and dirt ; failure to remove with soap and water accumulations at the 
mouths of the follicles ; irritation of the follicles by too frequent use 
of strong soaps or by the application of cosmetics ; contact with dyed 
veils ; and frequent fingering of the face which tends to disseminate 
over its surface pus-cocci and other microorganisms which are un- 
doubtedly active factors in some, if not all, stages and varieties of the 
disease. Unna and Sabouraud believe the organisms they find in 
seborrhcea are the active agents in the production of acne, with or 
without the addition of pus-cocci (see Seborrhcea and Dermatitis 
Seborrhoi'ca). Gilchrist 2 finds in acne-lesions bacilli similar to Sa- 
bouraud's micro-bacillus. From firm papules, in which clinical evi- 
dence of suppuration had not yet arvoeared, he obtained in a large 
percentage of cases pure cultures of the bacillus, which he terms 
Bacillus acnes. He succeeded in cultivating this organism and show- 

1 Cf. Kapp, Therapeut. Monats., 1907, March. 

2 Trans. Amer. Derm. Assoc, 1902, p. 105; and J. C. D., 1903, xxi., p. 107 
(with review of work done in this field by other observers). 



922 DISORDERS OF THE APPENDAGES. 

ing it to be pathogenic for mice and guinea-mgs. The sera of pa- 
tients affected with acne causes a clumping of the bacilli, from which 
fact he infers that " a specific toxic body derived from the presence 
of the bacilli in the tissues is absorbed in the blood, resulting in the 
production of the specific agglutinin." He suggests that the systemic 
condition found in many cases of acne, instead of having an etiological 
significance, may be the result of absorption of the toxines of bacilli 
acnes. Sollner, 1 after an extensive investigation of the bacteriology 
of acne concludes that while many microorganisms are found in the 
lesions of the disease their etiologic relationship has not as yet been 
determined. 

Pathology. — The earliest stage of the acne-papule is that described 
under comedo. Hyperplasia of the horny layer at the follicle-neck 
may continue without decided inflammatory changes and produce 
small, firm, normal-colored papules of the comedo type ; or complete 
occlusion of the duct of the gland may result in a simple retention- 
cyst. As a rule, however, the retained sebaceous secretion acts as a 
medium in which pus-organisms rapidly develop, producing an in- 
flammation which may be limited to the common excretory duct and 
the sebaceous gland, but which involves usually the hair-follicles and 
the tissues surrounding these structures. The pathological changes 
depend upon the extent and intensity of the process. All grades of 
severity are found between the superficial abscesses limited to the 
duct of the follicle, which disappear without leaving scars, to those 
instances where several glands and the intervening structures are in- 
volved in the formation of deep abscesses, which cause destruction of 
connective tissue and leave large disfiguring scars. In many of the 
nodules the inflammation is subacute in type, persistent, and accom- 
panied by infiltration of plasma-, mast-, and connective-tissue-cells, 
resulting in true connective-tissue proliferation and the consequent 
formation of indurated scars. The relation of microorganisms to the 
disease has been referred to above. 

Diagnosis. — The typical facies of acne vulgaris is readily recog- 
nized by the characteristic features already described. The reddish 
papules, pustules, comedones, and " lumps " in the skin of the face 
of a young subject; the evident involvement of the sebaceous glands; 
the history of a chronic affection destitute of itching and, though 
possibly picked, quite unscratched ; the occasional blood-crusts where 
lesions have been squeezed or incised, are all significant facts. The 
pustular syphilide of the face is not only to be differentiated by its 
share in the history of an infectious disease, but also by the occur- 
rence of characteristic crusts, its selection by preference of the regions 
about the nose and mouth, its evolution in groups, and its sequels in 
the form of superficial or deep ulcerations. Nevertheless, simple 
acne is common in syphilitic subjects. Potassium iodide is so fre- 
quently administered for the relief of syphilis, and in so large a ma- 
jority of cases induces its artificial acne, that the latter eruption often 
1 Munch, med. Wochenschr., 1904, No. 38. 



ACNE. 923 

precedes the evolution of the macular syphilide, and also with fre- 
quency masks the latter by a commingling of lesions. Simple acne 
is common also among those who are veterans of syphilis. Acne cer- 
tainly at times resembles variola, and cases of the former have been 
mistaken for the latter. In most instances the absence of fever and a 
brief delay will end any doubt. 

Treatment. 1 - — Acne is an entirely remediable disease in every case 
properly managed. Scars of ancient ravages of the affection are, it is 
true, indelible, but even these are smoothed down in the progress of 
time so that they become yearly less conspicuous and disfiguring. In 
all instances, whether the case is mild or severe the physician, who 
takes charge should explain to the patient that the disease per se tends 
to produce scarring, and that the best preventative of unsightly cos- 
metic results is intelligent treatment. 

The general treatment of acne requires a careful and exhaustive 
study of the special requirements of each individual case. A thor- 
ough investigation of the habits of living — food, diet, bathing, occu- 
pation — and bodily functions, according to the methods described in 
the chapter devoted to General Diagnosis, is essential at the outset. 

An important consideration, in undertaking the treatment of a pa- 
tient affected with acne, relates to any local or internal medication 
previously employed. A large proportion of all patients first claim 
the attention of the physician after ingesting drugs or making topical 
applications which have decidedly aggravated the original trouble. 
With or without the advice of others, such patients have often been 
engaged for months in swallowing various nostrums calculated to 
" drive out " disease, many of them containing potassium iodide ; or 
for the relief of headache have resorted freely to the use of proprie- 
tary preparations charged with acetanilid or potassium bromide; or 
have rubbed over the skin some patent salve containing tar. In 
every such instance treatment should be directed toward the relief of 
the artificial acne, after which the real condition of affairs can be 
recognized more clearly. The patient should be told to discontinue 
his or her former practice, to bathe the affected part with hot water 
at night, and after the surface is dried to apply any bland unguent. 
By these simple measures alone many cases of acne can be improved 
greatly, and some be relieved completely. 

The question of diet is of the highest moment. The kind and 
quantity should be suited to the occupation of the individual, as for 
the school-boy and the school-girl, or the adolescent employed in fac- 
tory or on the farm or in domestic labor. All over-fed subjects of 
acne are benefited in a high degree by reducing the quantity of food 
ingested especially in the items of meats and sweetstuffs. A milk- 
diet, or one composed largely of fresh fish, fruits, and the lighter 
vegetables, will usually brighten up the most obstinate case. Con- 
fectionery, highly spiced food, pastry, hot bread and cakes, sugars, 

1 For a discussion on the treatment of acne before the American Dermato- 
logical Association, see Trans., 1902, p. 119; and J. C. D., 1903, xxi., p. 136. 



T$. Magnes. sulphat., 


f 5ij ; 


60 


Acid, sulphur, dil., 


8 


Sodii chlorid., 


3.1; 


4 


Ferri sulph., 


gr- v; 




Cardamom, tinet. co., 


f3j; 


4* 


Aq. dest., 


ad f 3viij ; 


ad 240 


M. et filtra. 






Sig. A tablespoonful in a tumblerful of water before breakfast 



924 DISORDERS OF THE APPENDAGES. 

and fried articles are all excluded with great advantage. Alcohol 
is generally to be prohibited ; and it is idle to treat a severe case of 
acne in a young male subject who cannot for the time abandon the 
use of tobacco in every form. 

Since dyspepsia and constipation are frequently causal factors in 
the disease, it is necessary to correct these disorders when present. A 
blue mass pill or calomel on several consecutive nights followed by a 
saline laxative in the morning is usually indicated at the outset of 
treatment. The cascara compounds are especially valuable when it 
is necessary to continue the use of a laxative for more than a few 
days. Some modification of Startin's acid mixture, such as the 
following, will be found suitable for other cases : 



33 

M. 



Other cathartics, saline and alterative, will often prove service- 
able. The mineral waters, Hathorn, Carlsbad, Hunyadi Janos, Ra- 
coczy, or Kissingen, a tumblerful before breakfast, are exceedingly 
valuable in cases of habitual hepatic and intestinal torpor. When 
there is an acid form of dyspepsia the rhubarb and soda mixture, or 
milk of magnesia in dessertspoonful (8.) doses, will be serviceable. 
Mercurous iodide in small doses, true sodium salicylate, and the di- 
lute nitro-hydrochloric acid are often of value in aiding elimination. 
Some cases improve rapidly on taking each night enough castor-oil 
to cause a daily free evacuation of the bowels. Salol and other in- 
testinal antiseptics are sometimes effective. 

In those cases of acne in which inactivity of the large intestine is 
a factor, thorough irrigation of the bowel, together with daily exer- 
cises which will strengthen the abdominal muscles and stimulate peris- 
talsis, are often followed by complete recovery. For these patients 
abdominal massage is of great value. Large quantities of pure water 
drunk between meals aid greatly in the matter of elimination. Iced 
drinks should be avoided. As a rule, it is advisable to take but little 
liquid with food ; the unwholesome habit of rapidly bolting a meal 
without proper mastication is thus largely overcome. In many in- 
stances, however, a cup of warm, but not strong, tea, cocoa, or coffee 
at the close of the meal is helpful to digestion. Where gastric motor 
and secretory insufficiency is present pepsin, mix vomica, and dilute 
hydrochloric acid are valuable remedies. Pancreatin and diastase 
may be used if intestinal indigestion exists. 

Daily exercise in the open air is necessary to stimulate sluggish 
glandular systems into proper functional activity. Such exercise to 
be of value should be carefully adjusted, both in kind and in amount, 
to the needs of the individual. 



ACNE. 925 

A most important part of the treatment in every case is without 
question the daily bathing of the entire surface of the body (with 
exception of the face, which requires special attention as elsewhere 
shown ; and excluding the menstrual period in women) with water as 
cool as can be tolerated, followed by rapid sponging, and by brisk fric- 
tion with coarse towels or with a flesh-brush until the skin is glowing. 
Common salt may be added to this bath in the strength of | pound 
of salt to each gallon of water, unless contraindicated by irritability 
of the general body surface. The results of this treatment are ex- 
cellent in the majority of cases, especially in those in which the pa- 
tient has been accustomed to the hot or Turkish bath, which may 
aggravate affections of this class. 

In nervous and overworked patients sufficient sleep at regular 
hours should be secured, and when possible short periods of rest dur- 
ing the day should be obtained. In some of these cases the indiges- 
tion and consequently the acne can be made to disappear with no other 
treatment than ten minutes of complete physical and mental relaxa- 
tion before meals, and half an hour of comparative inactivity after 
eating. In a growing boy or girl relief of acne often can be best 
accomplished by shortening the school-hours, and by carefully select- 
ing studies and occupation adapted to the physical and intellectual 
development of the individual. 

The sexual life of both the married and the unmarried should be 
regulated according to the laws of hygiene. Pelvic disease, when 
this complication exists, should receive proper treatment ; especially, 
in these cases, should attention be paid to the general health, as pa- 
tients of this class are often chlorotic young women leading sedentary 
lives, or overworked at the school-desk, the sewing-machine, or the 
shop-counter. 

Internal medication for the relief of the disorder should be deter- 
mined largely by the general condition of the patient. Remedies to 
combat abnormal gastro-intestinal conditions have been mentioned. 
Cod-liver oil, iron, strychnine, phosphorus, the mineral acids, and 
the bitters are needed in chlorosis and cachexia. Calcium sulphide, 
long highly esteemed in the management of acne, is now discarded. 
Arsenic, however, is a valuable drug in many cases. The internal 
employment of ergot in full doses for the relief of acne has occa- 
sionally been followed by excellent results. Glycerin in teaspoonful 
to tablespoonful doses three times daily has been recommended. Ich- 
thyol is used empirically with success. 

In all cases, whether previously treated or not, which have been 
purged of suspicion of an artificial element, the local treatment is of 
prime importance, and in the perfection with which its details are 
observed lies the key to success. It is not the selection of one of the 
several remedies of the many advocated for the relief of the disease, 
nor yet the successive substitution of one for another to meet any 
transitory indication in each case, that conduces to the happiest re- 
sult ; but it is rather the use of a single method of recognized value, 



926 DISOEDEES OF THE APPENDAGES. 

and its skilful adaptation to the changing conditions of the disease. 

For many cases of acne the most rapidly effective local treatment 
is found in the skilful use of the x-ysljs. Under their influence pus- 
formation ceases, and the lesions gradually disappear. Prolonged or 
energetic treatment should not be employed in any case owing to pos- 
sible future atrophy of the skin. It is not necessary to produce visi- 
ble evidence of dermatitis to get good results. The method should 
always be employed in moderation both as to the quantity of x-rajs 
at each sitting and number of sittings during a given period. As a 
rule the method should be reserved for those cases resistant to other 
forms of treatment. In a large number of selected cases we have 
found it superior to other methods of local treatment. Many other 
observers, among them Pusey 1 and Campbell, 2 report equally favor- 
able results from the x-rajs. Good results are obtained by repeating 
the exposures twice weekly for three or four weeks using a tube of 
medium quality placed about eight inches from the surface exposed 
and excited by a mild current. The duration of each seance is 
limited to three, four, or five minutes. Recurrences happen less 
often after radiotherapy and are usually of moderate intensity. 

It is always necessary in the local treatment of acne to evacuate 
the contents of pustules, to express from the summits of papules 
(where are the orifices of sebaceous ducts) all densely inspissated 
plugs of sebum, and to remove any comedones present with the aid 
of the comedo-extractor. In many cases this operative treatment, 
especially the removal of comedones, is easier and more satisfactory 
after several days of the hot bathing and ointment-applications recom- 
mended in the following paragraphs. For the purpose of opening 
the superficial and smaller purulent collections an ordinary cambric 
needle of good size is decidedly preferable to a knife, and for the 
larger and deeper furuncular lesions a bistoury with a delicate and 
very narrow blade should be used. A slight degree of skill will here 
repay the operator. By counter-depression with the fingers the 
whitish-yellow or blackish orifice of the duct may be detected, and at 
this point the needle or the bistoury should be thrust sufficiently deep 
to insure removal of pent-up pathological contents. Should blood 
flow in droplets from any of these slight wounds, it is rather to be 
encouraged than repressed, as relieving the hyperemia and engorge- 
ment of the small periglandular phlegmon. In one or several sit- 
tings all lesions requiring such interference should carefully be at- 
tacked, and immediately after each operation, preferably while pus 
and blood still are oozing, the part is to be bathed for several minutes 
with water as hot as can be borne with comfort. For many reasons 
the hour before retiring is preferable, though not always practicable, 
in treating such cases, as then a soothing application can be made 
which may remain until the following morning. One or several of 

1 Pusey and Caldwell, Bontgen Bays in Therapeutics and Diagnosis, Phila- 
delphia, 1903. 

2 J. A. M. A., 1902, xxxix., p. 313. 



ACNE. 927 

these operations will do much to relieve the skin of its engorgement 
and retained inflammatory products. 

One of the most valuable methods of local treatment consists in 
first stimulating the sluggish skin marked with the lesions of acne un- 
til a slight dermatitis is produced, after which soothing applications 
are made until the reaction has subsided. By thus alternately 
stimulating and soothing the diseased portion of the skin distinct im- 
provement usually results in a relatively short time to the satisfaction 
of the patient. The treatment in detail as applied to the face would 
be as follows : 

The patient is seated before a basin of water, which is as hot as 
can be tolerated with comfort, and, with a pad of white flannel or a 
sponge of absorbent cotton or gauze, the face is bathed until the skin 
is thoroughly moistened and softened by the heated water and steam. 
From ten minutes to half an hour may well be employed in this way. 
While the face is still wet all pustules which have formed are emptied 
in the manner described above and a sufficient quantity of tincture of 
green soap (linimentum saponis mollis, U. S. P. VIII) is poured over 
the flannel or the sponge, with which the face is then thoroughly 
scrubbed. Finally, the skin-surface is cleansed with a surplus of 
the water, is carefully dried, and is anointed with a sulphur ointment, 
of a strength of 5 grains (.33) to 1 drachm (4.) to the ounce (30.) 
of cold cream salve and vaseline. In the morning the face is to be 
washed with hot water followed by cold. 

Some range may be observed in the employment of the two sub- 
stances named. Thus, the tincture may be diluted with cologne- or 
rose-water, one-half or more ; or the soaps employed, in less imperative 
cases, may be the best toilet-soap, Sarg's glycerin, or sulphur soap. 
The ointment, too, may be compounded by adding with the sulphur, 
half of the same quantity of resorcin to the ounce (30.) of base. 
This operation of steaming, soaping, and anointing is to be contin- 
ued, according to the severity of the case and the tolerance of the 
patient, nightly, or on alternate nights, until the face presents a dis- 
tinctly inflammatory reaction. After from two to ten days of this 
vigorous treatment the skin usually becomes reddened, slightly tumid, 
and often moderately furfuraceous. To the patient it feels tense, 
slightly painful, and as if made of leather. When this condition 
of artificial dermatitis appears the use of hot water, soap, and oint- 
ment should be discontinued, and for a few days some of the sedative 
lotions and ointments recommended for the treatment of acute eczema 
should be employed ; for this purpose the zinc oxide and liquor calcis 
lotion is especially well suited. When the artificial dermatitis has 
subsided the stimulating shampoo and ointment may be resumed, 
and the entire process be repeated. Gradually as the lesions disap- 
pear the vigor of the treatment should be relaxed ; first the soap, then 
the hot ablutions should be withdrawn, and finally a less stimulating 
application should be substituted for the sulphur pomade. 

In those cases where it is desired to produce stimulation and ex- 



928 DISOEDEES OF THE APPENDAGES. 

foliation quickly the paste recommended by Lassar is useful — that is, 
1 part of beta-naphtol, 2| parts each of vaselin and sapo viridis, and 5 
parts of precipitated sulphur — spread over the skin for from fifteen to 
twenty minutes, and then wiped off, when the surface is dusted with 
a simple powder. Soothing applications may be used with advantage 
before a second application. Lotions of mercuric chloride are of 
value where antiseptic and keratolytic effects are desired. 

Sulphur is rightfully accorded the first place among the reme- 
dies for the local treatment of disorders of the sebaceous glands, and 
aside from the ointment above mentioned is a constituent of many 
preparations of real worth in the management of acne. One of 
the best is Vleminckx's solution (see page 107), of which from 5 to 
50 drops in a tablespoonful of hot water may simply be mopped on 
the face and allowed to remain over night, or may be applied with 
gentle friction and massage. 

The following lotion is of service in resolving cases : 

^ Sulphuris loti, 5iij ; 12 

Sodas biborat., 3ij ; 8 

Glycerin., f 3vj ; 24 

Aq. dest., ad fgvi; ad 180 M. 

Sig. Shake well and apply freely, leaving a thin film of powder over face. 

Duhring recommends the following-: 



Sig. 



Sulphur, praecip., 

Glycerin., 

Alcoholis, 


5i.i ; 

f5ij; 

f Si ; 


8 

8 

30 


Liq. calcis, 
Aq. ros., 
Shake the vial before using. 




30 
60 



M. 



This mixture made up without the liquor calcis has also proven 
efficacious. 

Eesorcin, next to sulphur, is probably the most valuable remedy 
in acne as in other sebaceous gland disorders. It may be used in the 
above formulas in place of sulphur, or combined with it in strength 
varying from 2 to 10 per cent. Ichthyol and thiol are similar in their 
action to sulphur, and sometimes succeed when the latter fails. They 
may be used in ointments, in lotions, or combined with glycerin. 
The discoloration produced is easily removed, as both substances are 
soluble in water. 

Ammoniated mercury, 2 to 15 per cent., in lanolin or other sim- 
ple ointment is an effective remedy. Mercuric chloride is very gener- 
ally employed in the strength of from i to ^ grain (0.008-0.033) to 
the ounce (30.) of emulsion of bitter almonds as a lotion; and the 
protoiodide and biniodide of the metal are similarly applied in lotions 
and unguents, in the strength of from 5 to 10 grains (0.33-0.66) to 
the ounce (30.). One should be careful not to make use of mercu- 
rials at the same time with a compound of sulphur, lest a chemical 



ACNE. 929 

combination occur by reason of which mercurous sulphide (sethiops 
mineral) be precipitated upon the skin and produce the appearance of 
comedo. 

Van Harlingen employs with success in acne 1 drachm each (4.) 
of sulphureted potassa and zinc sulphate to 4 ounces (120.) of rose- 
water. Fox applies \ drachm (2.) of chrysarobin to the ounce (30.) 
of collodion. Taylor advises from 5 to 25 grains (0.33-1.66) of zinc 
iodide to the ounce (30.) of vaselin. 

For mild cases an excellent lotion is obtained by adding 2 drachms 
each (8.) of simple tincture of benzoin and glycerin to 4 ounces 
(120.) of distilled water, to which, where a more stimulating effect 
is desired, 1 ounce (30.) of cologne-water or of alcohol may be added, 
or 1 scruple (1.33) of sulphuretted potassa. 

For chronic and indolent cases a modification of the local treat- 
ment of acne may be employed by the aid of an instrument called the 
" massering-ball." This instrument consists of a stout, short handle 
of hard rubber, connected by means of a slender steel neck with a 
ball set in a steel socket, the small sphere rotating within the cup of 
the socket, as in an ordinary ball-and-socket joint. The free play of 
the ball is aided by its bearing upon a smaller ball set in the neck 
of the cup attached to the handle, which is fixed upon the socket at 
an angle sufficiently convenient for the operator, whose eye can thus 
better follow the play of the ball. The ball is constructed of hard 
rubber, and the area of its impact upon the skin at any moment 
is about that of the human thumb of average size similarly placed. 
When actually in use the ball travels with ease as well along the 
angles of the nares with the cheeks, the bridge and root of the 
nose, and the regions below the symphysis menti, as over the brow, 
the temples, the chin, and the cheeks. When necessary to cleanse the 
instrument the ball is detached by unscrewing ; but the entire instru- 
ment may be boiled without impairment of its usefulness. 

When ready for treatment the skin is first operated upon with 
aseptic needle and comedo-extractor until all pustules and subepider- 
mic foci are emptied and conspicuous comedones are removed. After 
this the surface is cleansed with a weak bichloride lotion or with alco- 
hol. The massering-ball is then rotated freely over the surface, and 
deep pressure is made upon the affected region, with the result of 
bringing into view groups of previously inconspicuous comedones, 
which are in turn removed by the extractor or "presser." Lastly 
massage of the surface is practised with the ball by the aid of a salicy- 
lated cocoanut-oil or by one of the sulphur unguents. 

In the milder forms of acne, and especially where the disease in- 
volves the trunk, precipitated sulphur alone, or better, in combination 
with other powders in varying proportions, is of great service when 
dusted on the affected parts daily. The diluent may include one or 
more of the following: starch, rice flour, zinc oxide, zinc stearate, 
and talc. 

Treatment by the opsonic method (see General Therapeutics) has 

59 



930 D1SOBDEES OF THE APPENDAGES. 

been tried in acne by a number of observers. 1 While it is perhaps too 
soon to pass final judgment the early promises of value in this form 
of treatment have not been realized. Recurrences are common, and 
the amount of time and extent of laboratory equipment required for the 
proper application of the most efficient technique are seldom at the 
command of the practitioner. 

In the severe forms of acne indurata and acne pustulosa treatment 
by the Bier's hyperaemic method may be found useful. Cupping 
glasses suited to the lesions may be applied, or the neck band may be 
worn, as described in the chapter on General Therapeutics. 

Prognosis. — The majority of patients, even when untreated, even- 
tually recover. This natural involution of the disease is commonly 
attained as the body arrives at the maturity of its development. 
Appropriate treatment has, however, a satisfactory influence in has- 
tening the recovery of practically all patients ; it also lessens the de- 
gree of subsequent scarring. A certain amount of cicatrix formation 
must be looked for in severe cases ; occasionally keloid occurs as an 
unpleasant sequel to the disease. Exceedingly rebellious and even 
grave cases occur in the cachectic, those long and improperly treated, 
and those who from necessity are continuously exposed to influences 
unfavorable to the involution of the disorder, such as the subjects of 
epilepsy habitually ingesting potassium bromide, and the victims of 
syphilis requiring persistent use of the salts of iodine. 

ACNE ROSACEA. 

(Rosacea, Gutta Rosea. Telangiectasis Faciei, K~jevus Aranetjs, 
" Beanoy-intose," Coppee-nose. Fr., Acne eosee, Cofperose; 
Ger., Kupfeeeose, Kupferfinne.) 

Acne rosacea is a chronic disease of the skin of the face, often de- 
veloped from or associated with the lesions of acne vulgaris, and is 
characterized by hypersemic areas, or patches of dull-red erythema, 
telangiectases, inflammatory papules, or growths which may attain 
the size of a hen's egg. 

Symptoms. — Acne rosacea is displayed most often upon the nose, 
cheeks, and chin, but may occur on any parts of the face, and rarely 
on the lateral regions of the neck. It is seen usually in middle life, 
and occurs rarely before the twenty-fifth year. In a first stage there 
is a more or less diffuse pinkish or dusky, but transitory redness, in- 
volving the extremity of the nose and its contiguous parts, which col- 
oration may extend from this region in a somewhat symmetrical fig- 
ure over the brow, cheeks, and chin. The redness may be spread uni- 
formly over the regions involved, or displayed in irregular, ill-defined 
blotches which vary greatly in size and shape. The spots may be 
roundish, radiating, stellate, linear, tortuous, or of fantastic outline. 

1 See Pernet and Bunch, B. J. D., 1906, xviii., p. 427, and Wright, Brit. Med. 
Jour., 1904, May 7. 



ACNE ROSACEA. 931 

The colors vary from a delicate rosy-pink to a deep-purplish crimson. 
Minute capillaries often ramify over the erythematous surface. The 
effect is a marked unsightliness, for which chiefly, or only, the advice 
of the physician is sought, as the affected parts give rise to few or no 
subjective sensations. Under pressure with the diascope the color dis- 
appears ; the surface seems cool rather than hot ; and the sebaceous 
glands are seen to be affected, as there is usually present either a 
seborrhcea oleosa or an accumulation of yellowish-white, moderately 
inspissated sebum in the patulous orifices of the gland-ducts. 

The disorder varies greatly with the general condition of the pa- 
tient. At times it may scarcely be perceptible ; again, after the stim- 
ulation produced by ingested food or by alcohol, after mental excite- 
ment, a paroxysm of coughing or laughing, or exposure to external 
irritation the lesions may be conspicuously deforming. This con- 
dition may endure for months or for years and then disappear, or 
may be succeeded by a second stage of the malady. 

In a second stage the redness becomes permanent, though subject 
to frequent variations in intensity, capillaries dilate passively and 
appear as conspicuous, tortuous, straight, or anastomosing lines of 
reddish color about the nose, cheeks, chin, or forehead. Firm, 
purplish-red, painless, pinhead- to pea-sized nodules or papules, at 
times pustules, often rise from the erythematous surface, and they 
either display minute superficial and tortuous blood-vessels in the 
integument with which they are covered, or they project from a base 
about which such a telangiectasis has very irregularly been developed. 
The lesions are apt to be intermingled with those of seborrhcea oleosa, 
comedo, or with acne vulgaris. When fully developed, this stage of 
the disease, though generally not productive of marked subjective 
sensation, produces an exceedingly conspicuous deformity. 

In the third stage (which is the most pronounced of the three) 
roundish, sessile or pedunculated, lobulated or pendulous, firm, elas- 
tic, pinkish-red, bluish, livid, or violaceous vegetations, traversed by 
a finer or larger network of blood-vessels, slowly develop about the 
affected part of the face, chiefly the nose. These vegetations may 
be single or multiple, and in the latter case may be isolated or so 
closely united as to be scarcely distinguishable from one another. 
The acneiform lesions seen in the second grade of the disease may 
here also be apparent. The nose is often cold to the touch when bright 
red in hue, and it may be oily or greasy in appearance in consequence 
of a seborrhcea oleosa of the part. The so-called " brandy-drinker's," 
" wine-drinker's," and " whiskey-drinker's " noses are of this class. 
In some cases there is a uniform and symmetrical hypertrophy of all 
the soft parts of the nose, which may thus attain colossal proportions. 
It is these extreme consequences of acne rosacea to which the term 
Rhinophyma has been applied. 

The course of the disease is slow, and in the larger number of 
patients does not produce the exaggerated types of the second and 
third grades. The lesions may persist indefinitely as indolent symp- 



932 DISORDERS OF THE APPENDAGES. 

toms of the malady in any one of its stages, or in a case in which 
there has been no new-growth of vessels or of tubercles may proceed 
to spontaneous involution. 

The Rosacea Acuminata of Crocker is characterized by the devel- 
opment on the face of few or numerous, pinhead-sized, convex, red 
papules with an occasional seropurulent apex. The description given 
suggests Folliclis (q. v.). 

Etiology. — The first and second grades of acne rosacea are com- 
mon in women either at puberty or near the period of the menopause, 
in those who are pregnant, or in those who suffer from utero-ovarian 
disease, irregular performance of the menstrual function, or chlorosis. 

The disease is seen also in men of early and of late adult life. 
In both sexes it may occur in anaemic and asthenic states; in both, 
also, its association with gastro-intestinal dyspepsia, constipation, and 
the immoderate use of strong tea and alcoholic drinks — beer, wine, 
and spirits- — is a matter of common observation. The new-growth 
of vessels and tubercles, with the rhinophyma of the advanced grade 
of the disease, is much commoner in men than in women. In those 
whose faces are bronzed by exposure to the weather the telangiectasic 
condition of the cheeks, rather than of the nose, is of frequent occur- 
rence. Veteran sailors and soldiers are thus commonly affected. Per- 
sons who have frozen the nose or the cheeks on one or more occasions 
and those suffering from trauma of these parts are similarly liable to 
telangiectases. Any externally or internally operating cause which 
tends to retard the capillary circulation in the superficial portion of 
the skin is capable of inducing this result, whether this retardation 
be due to direct or reflex vasomotor nerve action, or to toxines operat- 
ing directly upon the vessel walls. Acne rosacea at times is dis- 
played conspicuously in the mulatto. 

Pathology. — In the first stage of acne rosacea there is merely pas- 
sive hyperemia. The circulation in the superficial capillary plexus is 
retarded. Persistence of this condition for long periods of time re- 
sults in paresis of the capillaries, with their consequent dilatation 
and hypertrophy, phenomena which characterize the second stage, the 
sebaceous gland-disorder being a complication of the process. In 
the third stage the nodules are composed of newly formed gelatinous 
elements, which later are replaced by organized connective tissue. 1 
Dilatation and hypertrophy of the sebaceous glands, with dilatation, 
hypertrophy, and new growth of the superficial blood-vessels, and en- 
largement of those trunks which ascend from the corium are also 
found. There is no marked epithelial hypertrophy (Unna). 

The disease, however, is viewed differently by authors. By some 
its obvious connection with acne vulgaris is denied; by others it is 
regarded as a seborrhceal eczema. According to Besnier and Doyon, 
this disease represents the following: superficial or deep, at first in- 
termittent, then persistent, hyperemia ; sebaceous hypersemia (acne- 

1 For histopathology of the severe type — rhinophyma — see Salzer, Archiv, 1901, 
lvii., p. 409 (with review of literature). 



ACNE ROSACEA. 933 

eczema), in which there are unquestioned steatorrhea and implica- 
tion of the sebaceous glands with infiltration and possibly exfoliation 
of the skin; deep hyperemia with infiltration of the corium and 
plastic products about vessels, follicles, and perifollicular tissue; 
telangiectases, as described above; and hypertrophies of the peri- 
follicular derma with connective-tissue new-growth. 

Diagnosis. — Acne rosacea is distinguished from acne vulgaris by 
the presence of telangiectases, and of the hypertrophic growths which 
characterize fully developed lesions. The tubercular syphiloderm is 
recognizable by its tendency to ulceration and crusting and by the 
entire absence of telangiectasis. When the tubercles of syphilis are 
limited to the extremity of the nose (they are usually small in conse- 
quence of the influence of treatment) they often degenerate into 
characteristic, split-pea-sized, irregularly circular ulcerations, which 
are superficial in seat and frequently isolated. They leave similarly 
shaped and sized depressed cicatrices at the tip and neighboring parts 
of the nose. As the process is much more rapid than in acne rosacea, 
these lesions, considered in connection with the absence of telangiec- 
tasis, furnish the most significant diagnostic symptoms of the dis- 
order, for they often occur late in the history of syphilis, in individu- 
als in middle life, and in varying shades of a dull-reddish color, 
circumstances particularly favorable for confusion regarding the 
identity of the two diseases. Asymmetry of lesions more frequently 
characterizes syphilis than rosacea. 

Zoster from involvement of the superior maxillary branch of the 
trigeminus, with diffused redness of one side of the nose and efflor- 
escence of vesicles over its tip and ala, strongly resembles acne 
rosacea with pustular lesions ; but in zoster the painful character of 
the disorder, its limitation to one side of the face, its transitory 
career, and its vesicular lesions are characteristic. 

Lupus vulgaris, like syphilis, when occurring upon the nose, is to 
be recognized by the tendency of its papulo-tubercular lesions to 
ulceration and crusting, by the absence of vascularity, and by the 
frequent presence of characteristic cicatrices. Unlike syphilis and 
acne rosacea, however, the history of lupus vulgaris usually extends 
from early childhood. Lupus erythematosus is characterized by a 
definite outline, by a superficial infiltration and elevation of the bor- 
der of the patch, by an atrophic or scarred centre, by adherent scales, 
and by its symmetrical diffusion over much larger and defined areas, 
commonly extending from the bridge of the nose well on to the 
cheeks. 

Treatment. — So far as there can be said to be any internal treat- 
ment of acne rosacea, it is that employed in acne vulgaris; but in 
neither disease can such treatment be confidently described as effec- 
tive in the dispersion of the local lesions. The treatment is that of 
the patient rather than of his disease. When alcohol has been in any 
degree productive of the local effects the use of spirits, wines, and beer 
is to be interdicted ; but as regards confirmed rosacea this prohibition 



934 DISOBDEES OF THE APPENDAGES. 

will prove to be of little avail. The disease when resulting from 
spirit-drinking may persist after years of total abstinence. 

The diet should be of the character proper for the patient with 
acne. All imbibition of hot liquids, even tea and coffee in excess, 
should be restricted as tending to congest the blood-vessels of the face. 
Everything having the same result in the habits, the occupation, or 
the clothing of the patient should be, as far as possible, deprived of 
influence, as, for example, wearing of tight collars and corsets, work- 
ing over hot fires, etc. 

In many patients who are the subjects of rosacea, as distinguished 
from the younger class of sufferers from acne vulgaris, there are evi- 
dences of lithamiia, gout, and similar conditions, requiring even strin- 
gent rules in many particulars for the conduct of life. The use of 
sugar in many of these cases is to be restricted, meat should be for- 
bidden or permitted but once in the day, and other articles of food be 
selected with special care. Tobacco should never be allowed to male 
patients with well-marked symptoms, and the daily general bath de- 
scribed in the preceding chapter as of importance in the treatment of 
acne should here also be prescribed. 

All gastro-intestinal sources of mischief should also be set aside 
when practicable. In acne rosacea, even more than in acne simplex, 
dyspepsia and constipation are conspicuously effective factors. 

Internally, mix vomica, ergot and ergotin, ichthyol (ammonio- 
sulphonate), mineral acids and alkalies, and arsenic have been recom- 
mended. Most of these drugs are valueless in removing the symp- 
toms of the disease unless their use is indicated by the general con- 
dition of the patient. In gouty patients blue pill and alkalies, though 
not of themselves capable of relieving the rosacea, may serve to aid 
the patient ; the same may be said of the use of iron in chloro-ansemic 
women. 

The local treatment of acne rosacea is substantially that of acne 
vulgaris. Stimulating lotions of green soap, formalin, alcohol, mer- 
curic chloride, or sulphur (Vleminckx's solution is especially service- 
able), in connection with ablutions in hot water, are of the highest 
value. In addition, the various ointments containing sulphur, resor- 
cin, mercuric oxide, and iodides, and the continuous application of 
mercurial plaster should be employed if necessary. 

One of the most effective local treatments is by employment of 
radiotherapy. Under its use the nodules and diffuse redness as a 
rule disappear rapidly (for technique, see Acne Vulgaris). Telan- 
giectases are not removed by the .r-rays, but yield as a rule to photo- 
therapy. 

Phototherapy in a similar number of cases has given equally 
brilliant results, and is preferable to the x-rajs for circumscribed 
areas. When the disorder is more extensive, the results are achieved 
more rapidly and inexpensively with the .r-rays. 



ACNE ROSACEA. . 935 

Van Harlingen reports rapid results from the application, several 
times in the day, of a lotion composed as follows : 

]£ Sulphuris prsecipit., 3j ; 4 

Pulv. camphorse, gr. v; 33 

Pulv. tragacanth., gr. x; 66 

Aq- calcis,! -^ f -. ^ 3()| M 

Aq. rosas, J »*' ' ' 

Fox, of New York, applies chrysarobin in traumaticin, % drachm 
(2.) to the ounce (30.) ; but this drug should be reserved for in- 
tractable cases, as it may produce severe dermatitis. After the pro- 
duction of these effects, however, the benefits secured may be ap- 
preciable for months. 

In the second stage of the disease the treatment is the same as in 
the first stage, but when all the inflammatory phenomena have yielded 
and the causes 'of the local congestion have been removed, the vessels 
and remaining nodules may be destroyed by single or by multiple 
puncture of each with a fine cambric needle attached to the negative 
pole of a galvanic battery with six to ten elements in the circuit. 
This operation is better than the knife, and it may be regarded to-day 
as the effective method of removing blemishes produced by dilated 
blood-vessels in this stage of rosacea. The method is simple, readily 
executed, requires no anaesthetic, and is in many ways superior to 
other methods, to which resort should be had when electrolysis can- 
not be employed. Some vessels may be destroyed completely with the 
production of so slight a cutaneous cicatrix that in the course of a few 
months it cannot be recognized by the unaided eye. 

For details of this simple operation the reader is referred to the 
chapter on Hypertrichosis. For the cambric needle may often be 
substituted with advantage a platinum hypertrichosis needle. The 
vessels may be entered in one or several places, and the operation 
be repeated until the last thread-like evidence of their existence has 
disappeared. The number of cells brought into the circuit must be 
graduated somewhat to the requirements of each case and to the 
locality of the skin operated upon. Fewer cells can be tolerated for 
the lip and alse nasi than for the root of the nose, the cheeks, or the 
forehead. 

Brushing the part cautiously with solutions of caustic potash, 
from 10 to 30 grains (0.66-2.) to the ounce (30.) of water; and the 
local use of pure carbolic, chromic, pyrogallic, and glacial acetic 
acids, acetum cantharidis (Taylor), sulphur iodide, or solution of 
mercury pernitrate are forms of treatment which have been recom- 
mended but it is needless to say that use of such powerful agents 
must be attended with the utmost caution. Before these drugs are 
employed an effort should be made to produce exfoliation by spread- 
ing over the part a plaster made of green soap. Unna's mercurial 
plaster-mull is similarly applied. Kaposi highly recommends the 
solution of iodated glycerin employed by him in acne vulgaris (q. v.), 



936 



DISOEDEES OF THE APPEXDAGES. 



which solution is painted over the part from eight to twelve times 
daily for three or four successive days, and is immediately covered 
with gutta-percha tissue. 

Multiple scarification of all new-growths of the third stage after 
the manner of attacking lupus-nodules, erasion with a dermal curette 
or with a Braun spoon, and surgical ablation or decortication of 
tumors by ligature and knife, are also available. After any destruc- 
tive attack upon the diseased portions of the skin soothing lotions, 
fomentations, or ointments should regularly be applied. 

Prognosis. — A favorable prognosis can be given in cases in which 
the disease occurs in its milder forms. Even in cases complicated by 
marked telangiectasis and hypertrophy the results of treatment are 
often in the highest degree encouraging. Notwithstanding the most 

Fig. 188. 




Rhynophynia. 



energetic procedures, however, the vis-a-tergo of passive hyperemia, 
involving often the deeper and unassailed blood-vessels, may work its 
slow progress. For women the future is in general more promising 
than that of men. With the most unfavorable prognosis, however, it 
is to be remembered that the disease is one of deformity rather than 
of physical discomfort. 



ACNE VABIOLIFORMIS. 



937 



ACNE VARIOLIFORMIS. 

(Acne Frontalis, Acne Rodens, Acne JSTecrotica, Acne Atro- 
phica, Folliculitis Varioliformis, Necrotic Granuloma. 
fr., mlliaire scrofuleuse, folliculite cicatricielle ne- 
crotique.) 

Symptoms. — Acne varioliformis is characterized by the occur- 
rence over the brow, scalp, or other regions, of discrete, exceedingly 
indolent, reddish-brown, papulo-pustular, often umbilicated, lesions, 
which become covered with crusts, and eventually leave depressed 
superficial scars resembling those of small-pox. This disease is not 
to be confounded with that to which Bazin and other French writers 
once gave the name Acne varioliforme, viz., molluscum epitheliale 
(molluscum verrucosum, of Kaposi). 

The disease is relatively rare, and may be characterized by the 
development of few (but one or two) or very many lesions. In 
some instances the peripheral extension of a single papulo-pustule 
may produce a narrow annular sero-purulent chamber with a de- 
pressed firm centre. There is commonly a well-marked coincident 

Fig. 189. 




Acne necrotica. 



seborrhoea. Many of the lesions are traversed by lanugo-hairs. The 
subjective sensations are slight, at times there is itching. The dis- 
ease tends to recur and is exceedingly chronic in course. 

In exceptional cases the disorder occurs in other regions than those 



938 DISORDERS OF THE APPENDAGES. 

named above ; for example, over the dorsal and sternal aspects of the 
trunk, about the nose, and within and about the concha of the ear, 
the interscapular region, and the extremities. In one of the author's 
patients (the subject of the accompanying illustration) the disease 
left very disfiguring scars on the right ala of the nose. In some cases 
the affected regions are invaded so thickly that the resulting scars 
produce a cribriform aspect in the integument. Occasionally the 
arrangement of the lesions is linear or circinate. 

The variations displayed are exceptional, but worthy of note. 
Severe confluent, serpiginous, and very extensive developments of 
the malady may be seen. According to Boeck, the hue of the papulo- 
pustule is due to minute capillary hemorrhages, which later become 
invisible in consequence of tumefaction of the overlying integument. 

Etiology. — The sexes are represented nearly equally among the 
subjects of the disease, who are, as a rule, in or near middle life. 
Gastro-intestinal disorders are believed to have some etiologic rela- 
tion to the disorder. The causes of the disease are obscure, but that 
its origin, together with necrotic granuloma and folliclis, is in part 
mierobic, is well-nigh established. 

Pathology. — Fordyce 1 and Sabouraud state that the disease be- 
gins in the upper part of the hair-follicle, from which point it ex- 
tends to the entire follicle and to the sebaceous gland. Various micro- 
organisms are found in the lesions, but the active agent is apparently 
a staphylococcus. Sabouraud 2 believes the disease is always pre- 
ceded by seborrhoea due to infection with his micro-bacillus. 

The histological changes are similar to those of ordinary acne ex- 
cept that the process is limited distinctly in extent and almost in- 
variably terminates in a small central area of necrosis and subsequent 
sear-formation. Some of these cases may be due to the presence of 
the toxines of tubercle-bacilli. Acne varioliformis occurs in typical 
development upon the faces of the tuberculous. For further details 
in this connection, the paragraphs devoted to the Paratuberculoses of 
the skin (Necrotic Granuloma, Folliclis, etc.) should be consulted. 

Diagnosis. — The lesions are to be distinguished from the syphilo- 
derm named above, from acne vulgaris, and from variola. The points 
of distinction are: the absence of fever, present and precedent; the 
absence of other symptoms of syphilis ; the localization of the erup- 
tion ; and the absence of intermingled comedones and other symptoms 
of acne disseminata. The involvement of the scalp-surface is not 
alone sufficient to distinguish it, as syphilodermata and occasionally 
comedones are visible in the scalp above the brow. 

Treatment. — As a rule the disease yields readily after the use of 
antiseptic lotions or of ointments containing white precipitate, resor- 
cin, sulphur, mercuric chloride, formalin, or boric acid, though le- 
sions are likely to develop after suspension of treatment. In severe 
cases caustics or galvano-puncture may be required. Crocker employs 
potassium iodide internally with happy results. 

1 J. C. D., 1894, p. 152. 
'Annales, 1899, s. iii., x., p. 845. 



HYPERTRICHOSIS. 939 



THE HAIR AND HAIR FOLLICLES. 
HYPERTRICHOSIS. 

(Gt., virsp, in excess; 0/itf, hair.) 

(Hypertrophy of the Hair, Superfluous Hair, Hairiness, 
Hirsuties, Hypertrichiasis, Polytrichia, Trichauxis. Fr., 

FOILS ACCIDENTELS.) 

In the condition of hairiness the pilary filaments may be in- 
creased in number or size, or be developed abnormally with respect to 
the region or age of the person who is the subject of the anomaly. 

Fig. 190. 




The Russian 



Symptoms. — Hypertrichosis may be congenital or acquired, and 
partial or universal. In congenital hairiness it is common to see 
infants at birth with extremely long hairs on the hairy part of the 
body, this growth being usually replaced later by shorter filaments. 
Partial congenital hirsuties is illustrated in pigmentary nsevi. Uni- 
versal congenital hirsuties is a rare deformity, the entire body then 
being covered with longer or shorter downy hairs of various colors. 

Remarkable instances of universal congenital hirsuties are ob- 
served occasionally. The so-called " Russian dog-faced man " ( An- 
drian Jeftichjew) and his son were noteworthy illustrations of this 
anomaly. In most cases the influence of heredity is distinct and 
often is accompanied by defective dental development, such as entire 
absence of molar or of canine teeth. This anomaly may be exhibited 
in generations of one family. 

Acquired hirsuties may be partial or universal, much more com- 
monly the former. Thus, the hairs of the scalp or the beard may 
acquire an enormous vigor and length, reaching to the ground when 



940 DISOPDEES of tee appendages. 

the body is in the erect position ; or the hypertrophy of the hairs may 
affect the face of the child or the woman; and in persons of the sex 
last named either the upper lip, chin, cheeks, or all portions of the 
body usually covered by hairs in man, may be provided with a 
vigorously and symmetrically developed pilary growth. 

In all cases of hypertrichosis, whether congenital or acquired, the 
parts normally unprovided with hair are not the seat of the pilosis. 
The hairy regions in these cases may be provided with a few or many 
follicles, each of which is the seat of two, three, or even more 
filaments. 

As the growth of the beard in man is more or less associated with 
the maturity of the sexual organs, so the hypertrichosis of women and 
children is at times related to a precocious, perverted, or arrested 
function of the generative organs. The reported instances of men- 
struation in female infants and children usually include a descrip- 
tion of abnormal pilary development about prematurely developed 
pudenda ; and after the climacteric period, when some women con- 
spicuously in external appearance begin to resemble individuals of 
the opposite sex, either isolated, thick, bristle-like hairs develop over 
the chin or lips, or the extreme hirsute condition may be reached. 
Duhring 1 reported one such case, which is illustrated by a lithograph 
representing the face of -a woman provided with a superb beard. 

The influence of the sexual organs in the hypertrichosis of women 
is well demonstrated in the following case coming under our ob- 
servation : 

A married woman, thirty-three years of age, weighing one hun- 
dred and fifty pounds, mother of three healthy children, applied for 
relief of a general and facial hirsuties which .had resulted in the 
growth of a full beard and moustache. She had not menstruated 
for more than a year, and had been pronounced by an expert to be 
past the climacteric. During 1884 and 1885 the hairs of the face 
were removed in successive operations by the electrolytic method de- 
scribed below. Menstruation began while she was subject to the 
influence of the galvanic current in the operating-chair, and con- 
tinued thereafter irregularly, at times with intense pain and even 
menorrhagia. In 1886, after the last of the operations on the face, 
she rather suddenly lost in weight, decreasing to one hundred pounds, 
and began to menstruate regularly and painlessly. The hypertri- 
chosis of the general surface then spontaneously disappeared. In 
the latter part of the year she again conceived, and in March, 1887, 
being then free from hirsuties, she brought a healthy male child into 
the world. 

Halbau 2 has described hypertrichosis graviditatis as a symptom 
of pregnancy. 

As the result of the persistent application of stimulating and oily 
liniments over a region of the body (scapula, sacrum, sciatic notch, 

1 Arch. of Derm., 1877, in., p. 193. 

1 Wiener klin. Woehenschrif t, 1906, p. 6. 



HYPERTRICHOSIS. 941 

etc.), as also after traumatism by pressure or otherwise, a growth of 
long and numerous hairs is often produced. Care should be had in 
the management of cases of acne and rosacea in the persons of dark- 
skinned young women with luxuriant hair upon the head, lest a 
similar growth be produced upon the chin, cheeks, or nose. 

In cases of hypertrichosis the hairs may be colored variously, and 
the hypertrophy of downy hairs purely be numerical, or result in 
increase in the actual size of the shaft of the individual filaments. In 
neither case do the hairs present any anatomical peculiarities of 
structure. The localized congenital form of hirsuties is often char- 
acteristic of certain moles, known as ncevi pilosi. The surface of 
pigmentary moles (ncevi pigmeniosi) is often very extensively cov- 
ered with hairs of a dark color. Singular anomalies have been figured 
in which extensive regions (one or several limbs, the entire back, 
even the greater part of the body) were the seat of enormous pig- 
mented moles, covered with warts, fibromata, and other benign tu- 
mors, and clothed with a thick covering of longer or shorter hairs. 1 
All such cases exhibit a striking development in either symmetrically 
or asymmetrically disposed areas of distribution of cutaneous nerves. 

Hypertrichosis Neurotica. — The hypertrichosis neurotica of 
authors is that condition in which an excessive growth of hair has suc- 
ceeded spinal paralysis and other morbid conditions of the nervous 
centres. Under the title Trophoneuroses of the Skin in this work are 
described changes of a similar kind, in which there is association of 
hypertrichosis with hyperidrosis, changes in the nails, and even 
extensive tylosis of the palms and soles. 

Plica Polonica. — This was formerly supposed to be a disease 
peculiar to Poles (whence its name), but which has long been recog- 
nized as a result merely of persistent neglect, filth, the invasion by 
parasites, and consequent exudative disorders of the scalp. When it 
exists the hairs form a huge matted mass on the crown of the head. 
Hebra devotes an interesting chapter to the superstitious awe with 
which this accumulation of hairs, lice, and filth has been regarded. 
In Alaska a number of cases of plica have been observed among the 
natives of that region. A typical case of this deformity was lately 
presented at our clinic. 

Neuropathic Plica. — Le Page 2 described a case in which tan- 
gled " lumps " and " festoons " of hairs, flat, curled, looped, and inter- 
twined appeared on one side of the head of a girl seventeen years old, 
who had previously suffered from neuralgic pains in the site of the 
growth. Similar cases have been reported by Stelwagon 3 and others. 

Trichiasis is that condition in which the eyelashes, diverted from 
the normal line of projection, are turned inward so as to irritate or 
wound the conjunctival membrane. In Distichiasis a double row of 

1 See the author 's ease of nsevus lipomatodes in a child, the pilary growth being 
at that age undeveloped. J. C. T>., 1885, iii., p. 193. 

2 Brit. Med. Journ., 1884, i., p. 160. 

3 Diseases of the Skin, 5th ed., p. 908 (bibliography) . 



942 D1S0EDEBS OF THE APPENDAGES. 

filaments can be recognized, which are liable to induce similar ocular 
distress. 

Etiology. — The causes of hypertrichosis are obscure. Whatever 
determines the blood in excess to any region of the body supplied 
with hair-follicles indirectly may be the cause of hypertrophy of 
hair, a fact demonstrated in patients who, after applying sinapisms 
or liniments for years to the skin over the seat of a rebellious neu- 
ralgia, exhibit in this region an abundant growth of hair, often 
several inches in length. In women, whose sex renders the anomaly 
most deforming and distressing, it is noted, as has been observed, in 
precocious, perverted, or arrested activity of the sexual function. It 
may be a racial peculiarity, a family trait, an inherited anomaly, or 
an epiphenomenon in dwarfs, monsters, individuals affected with 
club-foot, insanity, and congenital deformities of several kinds. The 
neurotic conditions accompanying certain varieties of hirsuties may 
be inappreciable ; or evidently be due to traumatism ; or be exhibited 
in paralyses, muscular atrophy, etc. 

Treatment. — To Hard away, of St. Louis, Americans are indebted 
for the popularization of the method of removing superfluous hairs 
by electrolysis, first devised by Michel, of his city. Extensive pilary 
growths are now often removed by this method without subsequent 
reproduction of the hairs. A fine needle is introduced into the hair- 
follicle and gently passed down to the papilla at its base. This instru- 
ment is connected with the negative pole of a galvanic battery contain- 
ing six or more elements, the positive pole of which is in connection 
with a sponge-electrode held in the patient's hand, who is thus en- 
abled to make or break the circuit at will. When the current is passed 
a few minute bubbles of gas escape from the orifice of the follicle, and 
when the hair-papilla is destroyed the hair itself is readily extracted. 
The dexterity acquired by practice is requisite for the proper perform- 
ance of the operation, with a view particularly to the insertion of the 
needle at the proper angle into the follicle. Few patients complain 
of pain. The number of hairs removed at a sitting varies with the 
sensitiveness of the patient's skin. The resulting scar is quite im- 
perceptible or far less disfiguring than the hirsuties, suggesting the 
appearance of the male beard after shaving. Transitory macules, 
papules, pustules, and wheals occur at the site of puncture. Care 
should be taken not to insert the needle too deeply in the particularly 
vascular regions of the face, as an aneurysmal tumor might be pro- 
duced as a consequence. 

Every detail of this exceedingly simple operation has now been 
carefully studied by American operators, and the results, as con- 
firmed by our experience, may be given as follows : 

1. Any good galvanic battery may be employed. We use habitu- 
ally a forty-cell stationary battery, the switchboard of which is so 
arranged that any number of selected cells may be brought into the 
circuit. A galvanometer should be placed in the circuit indicating a 
current of from one-half to four milliamperes. The number of cells 



HYPEBTBICHOSIS. 943 

employed should vary with different individuals, different parts of 
the face, and on different days with the same individual— e. g., a 
smaller number is required when a patient previously operated upon 
returns after a somewhat long period of rest. Two to four cells only 
may be tolerated over the tip of the nose or the upper lip near the 
septum nasi. Twelve to twenty may be well borne, after some ex- 
perimenting, on an insensitive chin. 

2. The best needle is a carefully selected, fine jeweller's broach, its 
shaft and point being annealed by rapid passage through the flame of 
an alcohol lamp. It is often useful to have the point also well 
rounded on an emery-wheel. Irido-platinum needles are useful, but 
inferior to a broach for general work. 

3. The needle-holder should be simply a convenient insulated 
handle, sufficiently long to protect all the points of the operator's right 
hand from the current, and should be as light as possible, since a 
heavy holder interferes with delicacy of touch. Duhring's 1 holder, 
which is of the shape of a thin lead-pencil or pen-holder, is about four 
inches in length. The handle, or stem, is of hard rubber, through 
which passes a metallic rod, acting as a conductor for transmission 
of the current. The needle is inserted into the needle-holder proper, 
which is slotted, the needle being clamped immovably by means of a 
screw-nut. In the other end of the stem is an insulated inserting-pin 
attached to the cord leading to the battery. The instrument is con- 
venient to handle and altogether well adapted to the operation. 

4. The patient should be seated or reclining at ease in a good 
light, with the handle of the electrode connected with the positive 
pole of the battery in one hand, ready to press the sponge into the 
palm of the other. In this way, at the bidding of the operator, the 
patient makes and breaks the circuit at will. The sponge attached to 
the holder should be wet with a solution of salt and water. 

5. As to further details of the operation, it is well (a) to make 
and break the connection only when the needle is in situ, as this 
diminishes the pain of the operation ; (b) to introduce the needle with 
a gentle manipulation (acquired only by skill and well characterized 
by Uardaway as a " catheterization " of the hair-follicle), observing a 
certain degree of parallelism with the hair-shaft as the needle enters ; 
(c) to operate leisurely, making sure that the current is not broken 
by separation of the hands of the patient before the hair is completely 
free in the follicle. This last can be ascertained by gentle traction 
on the shaft in from twenty to forty seconds after insertion of the 
needle; (d) to operate in succession upon contiguous hairs when 
practicable, not selecting one here and one there, the latter course 
being productive of greater pain; (e) never to use the positive pole 
in connection with a steel needle, an error which results in the pro- 
duction of unsightly pigmented blemishes on the surface of the skin. 

The previous employment of preparations of cocaine both hypo- 
dermatically and by inunction — e. g., cocaine oleate — to relieve or 
1 Amer. Jour. Med. Sei., 1881, lxxxii., p. 142. 



944 DISOEDEES OF THE APPENDAGES. 

diminish the pain of the operation, may be followed by exceedingly 
unpleasant consequences. A dermatitis thus induced may persist 
for months. 

Prince, of Boston, lays stress upon the accurate regulation of the 
current by the aid of the absolute galvanometer, which we have found 
in practice useful but not essential. Fox, 1 of New York, reports a 
gradual decrease in the number of hairs returning after operation, 
proportioned to the improvement in the instruments and the skill of 
the operator. The percentage of such returns varies with these 
conditions. 

All patients aifected with hirsuties are not to be advised the 
operation. We have declined to operate in many cases which 
were not deemed to belong to the class in which the best results of 
the operation may be expected. Young and vigorous women, usually 
unmarried, may point out hairs to be removed that are merely full- 
developed filaments of a thick downy growth, all the hairs of which 
are rapidly pushing to equal maturity. Here the operation itself, 
by inducing hyperemia of the skin, may simply hasten the hyper- 
trichosis actually in progress, and thus aggravate the disorder. In 
most cases, when an operation is undertaken, both parties should 
fully understand the possible issue. It is a question whether it lies 
within the legitimate sphere of the physician to remove superfluous 
hairs from the habitually covered breasts and arms of women. 

This operation has unfortunately found its way into the hands of 
the unprincipled and the ignorant, who, in their efforts to extract 
money from the credulous, have in some of the larger cities brought 
electrolysis for hypertrichosis into ill repute. The operation is, 
however, all that can be desired if only it be performed with suffi- 
cient skill and conscientiousness ; but if hairs are rapidly plucked 
away from their follicles while an electric current is passing merely, 
the return of each filament is prompt and mortifying to the patient. 
It should, therefore, be understood as a procedure requiring ample 
time on the part of the operator, and either fairly good vision 
or eyes aided by a mounted lens. Not more than from forty to 
sixty hairs can be removed in an hour by an expert operator; and 
there are few who can work with advantage more than one hour at a 
sitting, or more than one or at most two hours in a day. 

Hairy nsevi may be removed by complete excision, but removal of 
the hairs by electrolysis will sometimes result in disappearance of the 
entire growth without such operation. 

In 1897 Freund 2 reported that he had succeeded in removing the 
hairs from a large hairy naevus by using the x-rays. The method was 
developed further by Schiff and Freund, 3 and has been employed 
since by many observers, including Benedikt, Ehrmann, Jutassy, 
Pusey, 4 and ourselves. 

1 The Use of Electricity in the Eemoval of Superfluous Hair, etc., Detroit, 1886. 

2 Wien. med. Wchnschrft., 1897, xlvii., p. 428. 

3 Ibid., 1898, xlviii., p. 1058. 

4 Pusey-Caldwell, The Koentgen Eays in Therapeutics and Diagnosis, Phila- 
delphia, 1903, p. 339 (with bibliography). 



HYPEBTBICHOSIS. 945 

After many years' observation of patients subjected to radio- 
therapy for removal of superfluous hair, the author has abandoned 
its use. While in some cases the result is satisfactory alike to phy- 
sician and patient, the probability of future telangiectasia is so great 
as to be prohibitive of its continued employment. 

Depilatories for the removal of superfluous hairs operate by the 
destruction of the filament without obliteration of the papilla. The 
consequence is that the hairs are reproduced in the course of about a 
fortnight. Most of the compounds used for this purpose contain 
either calcium sulphate, arsenic sulphate, or barium sulphide, made 
into a paste with warm water. This paste is applied over the hairy 
surface with a spatula, and is permitted to remain until it dries, or 
produces a sensation of heat or burning, a period usually requiring 
ten minutes. It is then rapidly removed by scraping with a spatula, 
and the surface thoroughly cleansed with warm water, after which 
the skin is anointed with cold-cream salve or other similar unguent. 

Of these depilatories Duhring recommends the following : 

I£ Barii sulphidi, 3ij ; 8 1 

Pulv. oxid. zinc, "I aa 5iij ; aa 12 

Pulv. amyl., J | M. 

To be prepared in form of an impalpable powder, which, just before using, 
is to be mixed with water to form a thin paste. 

The following are formula? devised by French authors : 

]£ Sodii hyposulphit., 3«j ; 121 

Calcis, \ aa 3x; aa 40 

Amyli pulv., j | M. 

To be finely triturated, and, when used, to be made in a thin paste with 
water. (Boudet.) 

# Calcis, 3j; 4| 

Sodii carbon., 3jss; 6 

Cerat. adipis, §j; 30| M. 

To be applied as a depilatory in the manner of a paste. 

All these formula? require caution in their use, and they should 
rarely be intrusted to patients themselves. 

Shaving may be practiced upon the hirsute face of women, and, 
with a similar end in view, also epilation ; the latter, particularly in 
cases of hypertrophy of the hair limited in extent. Partial success 
has attended the thrusting into the follicles of needles previously 
dipped in caustic solutions, or heated in various degrees, but these 
methods are inferior to electrolytic destruction of the hair-papilla?. 
The hairs may be rendered less conspicuous by bleaching them with 
frequent applications of hydrogen peroxide. Bulkley states that a 
thorough use of this remedy retards the growth of fine hairs. 



946 DISOSDEES OF TEE APPENDAGES. 

ATROPHIA PILORUM PROPRIA. 

(Atrophy of Hair.) 

Atrophy of the hair may be either symptomatic or idiopathic. 
Illustrations of the first-named condition are observed in phthisis, 
syphilis, seborrhoea, parasitic affections of the scalp, and in almost all 

Fig. 191. 




Congenital atrophy of hair. 

general diseases interfering with the nutrition of the pilary growth. 
The filaments then become dry, lustreless, friable in both longitudi- 
nal and transverse diameters, and diminished in each dimension. 

There are several recognized forms of idiopathic atrophy of the 
hair. One of these forms exists in those long hairs which are seen to 
be irregularly thinned or flattened in the shaft, and split at the point 
into two or more recurving fibrillar, a condition noted, for the most 
part, in few hairs scattered among those of full development and 
vigor. This especially localized atrophy seems to be peculiar to one 
or more follicles merely ; and is analogous to the condition in which 
there appears among the vigorous pigmented hairs of early life a 
single blanched filament. 

FRAGILITAS OMNIUM, i 

Under this title a number of disorders, due to atrophy, and pro- 
ducing fragility, splitting, or curling in abnormal directions of pilary 
filaments, have been described by authors. 

Under the title : " Undescribed Form of Atrophy of the Hair 
of the Beard " Duhring 2 reports an affection in which, either at the 
bulb or at a variable distance from it but within the follicle, there is 

1 See Jackson, Diseases of the Hair and Scalp, New York, 1890, and J. C. 
D., 1903, xxi., p. 473. 

2 Amer. Jour. Med. Sci., 1878, lxxvi., p. 88. 



TRICHORRHEXIS NODOSA. 947 

fission of the hair-filaments into from two to four stalks with coinci- 
dent atrophy of the bulb itself, and consequent irritation of the sur- 
face. Duhring's patient exhibited to a marked degree the species of 
hypochondriasis to which the subjects of disease of the hair seem spe- 
cially prone. This disorder is not induced by a parasite. 

In 1887 a gentleman applied to us for advice who was in a fair 
condition of general health, but the hairs of whose beard exhibited 
the symptoms described and figured by Duhring. Photo-micro- 
graphs of specimens of these hairs show clearly that in every case the 
fission of the filament extended completely to the base of the follicle 
and produced there irritation. The hairs over several square inches 
of surface were thus uniformly affected, normal filaments being in 
such areas absent. The interfollicular spaces, however, seemed to be 
abnormally widened, as though in these areas such normal hairs might 
have fallen in consequence of a species of alopecia. The disease 
was much more strongly marked on the chin than on the cheeks or 
the upper lip. The curling of some of the splinters was complete 
and characteristic. In Parker's 1 case there were similar features. 

When the fission exists solely at the free ends or in the shaft of the 
hair, the morbid condition is obviously different from that described 
above. Several, many, or all of the hairs may be affected, the split- 
ting extending only a short distance from the point of the filament, 
or many inches beyond. The splitting of the shaft of long hairs in 
women without involvement of the point is due most commonly to the 
thrusting of sharp-pointed hair-pins through the hair-coils on the 
scalp, a single thrust being thus capable of wounding a large number 
of hairs in a single braid. 

In one form of this affection the hairs break off short when ener- 
getically brushed with the hand. The possibility of the defect in 
hair development being due to keratosis pilaris should be carefully 
considered. 

The treatment of these conditions is primarily hygienic as re- 
gards both the general health of the patient and the preservation of 
the hair from artificial methods of management (hot ironing, curling, 
singeing, crimping, and wounding with hair-pins). 

Locally, stimulation with shampooings, and inunction with bland 
oils, and simple remedies are useful. The region of the beard when 
affected should be shaved regularly. 

TRICHORRHEXIS NODOSA. 

(Trichoptilosis [Devergie], ISTodositas Crustittm, Trichoclasia, 
Clastothrix. ) 

Trichorrhexis nodosa is a disorder of the hairs, first described by 
Wilson in 1849, and since that time it has been the subject of ex- 
tensive discussion. It affects the male beard mostly. The diseased 
^rit. Med. Jour., 1888, ii., p. 1335. 



948 



DISORDERS OF THE APPENDAGES. 



hairs show one or more nodular enlargements which on careful exam- 
ination are seen to be due to partial transverse fracture of the hair 
shaft. 

Extensive bacteriological studies of the diseased hairs have been 
made with negative result and it has been found to affect bristles of 



Fig. 192. 



,V ; <; r ^ 




Trichorrhexis nodosa. (After Schwijijiek.) 



hair brushes. Sabouraud 1 concludes that the disease is a fracture of 
the hairs of the beard and of brushes due to mechanical friction and 

1 Annales, 1903, s. iv., iv., p. 947. 



MONILETHRIX. 949 

the use of lather. Brocq produced the disease in his own beard by 
friction. 

Fig. 193. 




" 



Trichorrhexis moniliformis. (Heidikgsfeld.) 

The only treatment necessary is to discontinue the constant use 
of the hair brush. 

MONILETHRIX. 

(MoNTLIFOKM, BEADED HaIES ) PlLI ANNULATE Get., RlNGEL- 

haaeeist; Fr., Aplasie monilieoeme inteemittente.) 

Monilethrix is a somewhat rare condition first observed by Smith 
(as described below), and since by numbers of others, including Luce, 
Anderson, Crocker, Lesser, and Behrend. 1 A patient affected with 
this disease was exhibited at the International Congress of Derma- 
tology held in London in 1896. Like the forms of fragility described 
above, the hairs are peculiar in exhibiting along the shaft a succes- 
sion of rings or nodes, between which are narrower portions of the 
shaft, of a color lighter than that of the pigmented nodules or annu- 
lar portions. The result is a characteristic checkered appearance of 
the hairs, often associated with alopecia in varying grades. Frac- 
ture always occurs in the internodular part, the fractured extremity 
having a characteristic brush-like stump. These conditions are due 
to atrophic changes in the internodular parts, with better develop- 
ment in the pigmented and thicker portions of the shaft, the whole 
being due to nutritive changes which Virchow, Hallopeau, and others 
explain as due to a periodic aplasia of the hair-papilla. The obvious 
1 For complete bibliography, see Gilchrist, J. C. D., 1898, xvi., p. 157. 



950 



DISOEDEES OF THE APPENDAGES. 



symptoms are clearly the result of a profound process, originating 
probably in the trophic nerves. 

The disease is believed by Brocq and also by Hallopeau to be a 
manifestation of keratosis pilaris. It is most frequently seen in 



Fig. 194. 




Trichorrhexis nodosa. i Heidixgsfeld.) 

succeeding generations of a family and also in individuals affected 
with the disorder. The bacteriology is negative. 

The treatment is through general and local improvement of the 
nutrition. 



NODOSE SWELLINGS OF THE SHAFTS OF THE HAIR. 

Smith, 1 of Dublin, first reported a case of this disorder. Photo- 
micrographs of some of the hairs from this patient exhibit no fragility 
at the nodes, which beginning near the scalp are displayed regularly 
along the shaft, the fracture being always internodular. The spheri- 
cal swellings along the shaft are also pigmented in a brown hue, and 
these pigmented nodose swellings, contrasting with the non-pigmented 
color of the unaffected portions of the shaft, give the hairs a singularly 
" checkered " appearance. Xo parasite is discernible in any of the 
specimens. 

Expansions and Fissures of the Hairs. — Michelson, under this title, 
discusses the abnormalities of the pilary system, instances of which 
are cited above, and he concludes as to the most of them that they 
are not separate diseases, but are expressions of an abnormal dryness 
and brittleness of the hairs due to atrophy. Cases of broom-like 
Assuring and division of the shaft into the larger longitudinal splin- 
ters he regards as equivalent processes, both beginning by a cuticular 
loss and often merging into each other. 

This view may be sound with regard to a number of these rare 
affections; but even a superficial examination of the longitudinal 

1 Brit. Med. Joura.. 1880, L, p. 654. 



LEFOTHBIX. 951 

splinters shown in Duhring's and the author's cases reveals the fact 
that the shaft represented by the sum of all its splinters is greater 
than that of the average hair in diameter and circumference. Even 
the naked eye can recognize this fact. The separation of the epilat- 
ing-forceps in seizing a single hair, in the case of our patient, was 
equivalent to the grasping of as many sound filaments as are repre- 
sented by splinters. 

The therapy of these cases is not well determined. Michelson be- 
lieves shaving to be useless, and he recommends systematic shampoo- 
ing and oiling. Arsenic internally is worth trying in all cases in 
which it is not contraindicated. 

LEPOTHRIX. 

(Gr., leirlg, scale; dpif, hair.) 

(Trichomycosis ISTodosa, Trichomycosis Palmellina. ) 

This disorder, first described in 1869 by Paxton, and since recog- 
nized by Patteson, Pick, Babes, Barthelemy, and others, affects the 
hairs, chiefly of the axillae and the genital regions. The filaments 
are dry, brittle, roughened, and loosened in their follicles. Under 
the microscope the shaft is seen to be either for a great part or for 
the entire length ensheathed in a concretion which may here and there 
be interrupted by furrows — a diffuse form of the affection. In a 
nodose form there are irregularly placed spherical masses, isolated 
from one another and more numerous toward the point than near the 
implanted extremity of the shaft. Crocker describes also circular 
and well-defined masses, lying upon but not surrounding the shaft, 
three times the diameter of the shaft, and containing fibres of the 
cortex that had been split by the concretion. The fracture may be 
clean or be brush-shaped. The nodular masses are firm, gluey, well 
attached to the shaft, and reddish brown to blackish in shade. At 
times reddish sweat of the axillae, due to micrococci, has been a coin- 
cident symptom. 

The nodes are found to be made up of chains of spherical or of 
elliptical micrococci, which penetrate the cortical layers of the hair 
with ease in regions of considerable moisture and sweat. The micro- 
organisms at first obtain access by minute separations of the cuticle of 
the hair, and they eventually penetrate more deeply, breaking up the 
cortical portions. While thus multiplying, a homogeneous substance, 
similar to the chitine by which the louse fastens its eggs to the hair, 
forms the bulk of the concretion in which the colonies of cocci are 
lodged. 

The treatment is by shaving and external applications of mercuric 
chloride (1:2000). 



952 DISORDEBS OF THE APPENDAGES. 

CHIGNON FUNGUS. 

(Beigei/s Disease.) 

This affection is discovered upon false hairs, which exhibit on 
their shafts dirty-brownish nodes, due to masses of parasites. The 
fungus has not definitely been distinguished. The nodes are strung 
irregularly along the shaft of the hair. 

TINEA NODOSA. 

(Piedea Nostras.) 

This disorder, first discovered by Morris and Cheadle, 1 and since 
reported by Crocker 2 and Thin, 3 affects the hairs of the beard or the 
moustache. Xodular concretions are developed irregularly along the 
hair-shaft, the bulb remaining unaffected. Under the microscope the 
growth was recognized as an ensheathing mass which when the hairs 
were split penetrated below the cutis. It was seen to be made up of 
fungus-spores smaller than those of tinea trichophytina. The hairs 
are brittle and break or split. 

The treatment is by shaving or clipping, with the application of 
parasiticides. 

CANITIES. 

(Lat., canus, white.) 

(Trichoxosis Caxa, Poliothrix, Poliosis, Hoarixess, Grayness 
or Whitexess of the Hair.) 

Symptoms. — In this anomaly the hairs appear in all shades of 
whiteness, from dirty gray or yellowish white, to a steel-gray or sil- 
very white. This may be either a general or a partial, congenital 
or acquired, physiological or pathological, prematurely, rapidly, or 
gradually acquired condition. General congenital whiteness of the 
hair? is seen in albinismus, where pigment has never colored the 
filaments. Partial congenital whiteness is occasionally seen in 
patches, limited in size and varying in color from pure white to a 
deeper hue, that from birth do not receive pigment in due propor- 
tion, thus contrasting with the pigmented filaments by which they are 
surrounded. This is sometimes a family peculiarity. 

Physiological decoloration of the hairs in variable shades is the 
well-known result of advancing years. When premature, it may 
occur early in life and result from pathological causes or be due to in- 
dividual or inherited peculiarities. It may occur gradually or sud- 
denly ; in the former case the hairs usually pass through varying 
shades of gray to white, and this at any period after (occasionally 

1 Lancet, 1879, i., p. 190. 

2 Dis. of Skin, 3d eel., p. 1176. 

3 Lancet. 1882, ii., p. 742. 



CANITIES. 953 

before) puberty, though commonly after middle life is reached. At 
first a few scattered hairs are bleached : then these multiply and so 
gradually the whitening occurs ; in other instances the bleaching is 
general, symmetrical, and uniform. In yet other cases even in senile 
hoariness the canities is at first circumscribed, the hairs of one part 
of the scalp blanching before others, the hairs of the beard whitening 
before the scalp or vice-versa. Kecurrence to the darker shades is 
noted rarely. Leonard, of Detroit, 1 cites a number of curious in- 
stances in which changes of this sort have occurred. Generally, how- 
ever, canities of advanced years is progressive and permanent, occur- 
ring earliest on the temples and the beard of man, then involving the 
vertex of the head. Finally, the hairs of the entire body-surface may 
undergo similar pigmentary loss. 

The coloring of the hairs of the head is, to a greater extent than 
commonly is appreciated, subject to variation from the operation of 
external causes. Thus, washing the hair with alkaline solutions has 
a bleaching effect, while profuse sweating, inunction with fats, sub- 
jection to smoke, and the temperature-changes of the summer have the 
contrary influence, the last named being associated possibly with in- 
creased sweating in the hot season. 

Cases of sudden blanching of the hairs, occurring, for example, 
in a single night, are sufficiently numerous and well authenticated 
to be admitted as among the rare possibilities of a clinical experience. 
Nervous disorders, both centric and peripheral, such as long-continued 
mental depression, melancholia, paralysis, neuralgia, and traumatism 
of nerves or of nervous centres, may be followed by more or less rapid, 
general or partial, and permanent canities. The same result may 
follow wasting disorders, such as typhoid fever, tuberculosis, syphilis, 
and malarial fever, in which cases, as distinguished from the others, 
pigmented hairs eventually may replace those which were white. 
The first hairs springing from a patch of alopecia areata in which re- 
pair is in progress are often white or whitish, and are replaced later 
by those of normal color. The pressure of a truss or of a corset has 
produced patches of vitiligo and canities. 

Landois has shown that many instances of suddenly occurring 
canities depend solely upon the rapid appearance of air-bubbles in ex- 
cess of the average number in the hair-shaft. 

In the rare affection known as Kinged Hair the pilary shafts 
present alternately white and pigmented segments. 

Etiology.— Whitening of the hair may be senile in origin, in 
which case it is customary to declare it to be physiological ; or be due 
to heredity ; to deficient nutrition or innervation of the hair-follicles ; 
to functional or organic nervous affections (fright, facial atrophy, 
etc.) ; or to local chemical action upon the hairs. Premature canities 
in young adults is often associated with the occupations of life, being 
much commoner in men who from necessity have the head habitually 
covered and who yet lead sedentary lives. 

x The Hair, its Growth, Care, Diseases, and Treatment, Detroit, 1880. 



954 DISORDERS OF TEE APPENDAGES. 

Pathology. — The color of the hair is dependent upon the pigment 
situated in the matrix and between the horny cells, and upon the 
natural yellowish color of the dried horny cells. In source and char- 
acter the hair-pigment is undoubtedly identical with that of the skin 
in general. This has been considered with chloasma. Decoloration 
of the hairs may be due to failure of supply or to removal of pigment ; 
to unevenness of the hair-surface (by which light is refracted) ; or 
to air-bubbles between and within the fibre-cells. In senile and pre- 
senile decolorations there is commonly actual diminution of pigment. 
Rapidly occurring canities is ascribed to the sudden appearance of air- 
bubbles in quantity in the shafts of the hair. Alterations of color in 
the hairs are attributed to successive periods of activity and rest in the 
pigment-producing cells. 

Treatment. — The chief means of remedying premature canities 
is by the action of dyes, which are, in the main, compounded with 
solutions of silver nitrate, lead acetate, and ferrous sulphate. The 
main objections to their use are the fact that the dyed hair never has 
the exact hue and lustre of naturally tinted filaments and thus rarely 
deceives the eye of the observer, as also the disagreeable coloring of 
the scalp which results from incautious use of the dye, and the conse- 
quent liability to irritation of the surface. These substances are not 
known to have a deleterious effect upon the general health. Kaposi 
gives the following formulae for hair-dyes : 

To obtain a black color — 

^ Argent, nitrat., 
Ammon. earb., 
Unguent, adipis, 

Or 

I£ Argent, nitrat., 
Plumb, acetat., 
Aq. Cologn., 
Aq. ros., 

To obtain a brown shade — 

5 Acid, pyrogal., 
Aq. Coiogn., 
Aq. ros., 

Anderson first applies a lotion of mercuric chloride, 2 grains to 
the ounce (0.133 to 30.), and follows this with a solution of sodium 
hyposulphite, 1 drachm to the ounce (4. to 30.), for the production 
of a jet-black shade. In the way of constitutional treatment, he sug- 
gests in cases of accidental presenile blanching strict attention to the 
general health and arsenic internally. 



gr. xv ; 
gr. xxij; 




1 

1 

30 


5 
M. 


5j; 

gr. xv; 
gtt. xv; 
ad ipij; 


ad 


41 
1 
1 
90| M. 


gr. xv ; 
3ss; 

3J SS ; 




1 

2 
45 


M 



ALOPECIA CONGENITA. 955 

ALOPECIA. 1 

(Gr v ahumi!;, a fox.) 

(Calvities, Defluvium Capillorum, Deficiency of Hair, Bald- 
ness. Fr., Alopecie; Ger., Kahlheit.) 

The simple term alopecia is no longer descriptive of a disease, but 
only of a symptom, loss of hair, which occurs in a large number of 
morbid and even physiological states. For convenience of description 
the alopecias may be enumerated as congenital, premature or presen- 
ile, and senile. Alopecia areata being distinctly different from the 
affections generally associated with alopecia simplex, is considered 
separately in these pages. 

ALOPECIA CONGENITA^ 

(Hypotrichosis, Alopecia Adnata, Oligotrichia Congenita, 
Congenital Alopecia Areata, Universal Congenital 
Atrichia. Fr., Alopecie Congenitale.) 

Under these several titles has been described a group of rare cases 
in which the symptoms, though possibly originating from different 
causes, are suggestively similar. The following named conditions are 
often designated by the name given : 

1. Complete and universal absence of hair at birth, not succeeded 
later in life by a pilary growth. This is believed to be an intra- 
uterine atrichia due to failure of development of the hair pouches. 

2. Universal congenital hypotrichiasis, in which hairs develop in 
all regions of the body, but later fail to be succeeded by filaments 
normal in length, vigor, color, and texture. Two subvarieties of this 
condition have been recognized : (a) The infant at birth is provided 
with the relatively long hair of most normal infants. This in due 
time falls and is replaced by a scanty down which later in life fails 
to ensure a normal hirsuteness of the scalp, (b) After birth, the 
infant fails to lose the temporary hair of the scalp which persists 
but later produces a scanty or ill-developed pilary growth. 

3. Complete or partial absence of hair at birth in definitely cir- 
cumscribed regions, such as the scalp, the brows, the pubes, or the 
axilla?. 

1 Literature: MacKee, New York, N. Y. Med. Journ., 1906, July 28; Kreuz- 
fuchs, Haarausfall und Hypertrichosis, Wien. med. Presse, 1906, No. 51; Barton, 
A Case of total Alopecia following the use of cantharidin, The Lancet, 1905, Oct. 
21, p. 1181 ; Saalf eld, Zur Behandlung des vorzeitigen Haar Ausf alles, Therap. 
Monatsh., 1905, Nr. 4; Meyer, Toxic origin of Alopecia (Organismus und Krank- 
heit), Deutsche Praxis, 13, Nr. 21; d'Amato, Die Praventivebehandlung der 
friihzeitigen Kahlheit, Bollettino delle mal. vener, sifil, urin. e. della pelle, 1905, 
No. 7-8; Le Fevre, Falling hair; what can we do for it! Amer. Journ. Derm, 
and Genit.-urin. Dis., 1905, No. 10; Eck. Beitrag zur Ubertragbarkeit der 
Alopecie, Journ. Des Mal. Cutan. et Syphil., 1908, Heft 3-4; Echner, Alopecia, 
Am. Jour. Med. Sci., 1905, April. 

2 For bibliography see a paper by the author published in J. C. D., December, 
1908. 



956 DISOEDEBS OF THE APPENDAGES. 

4. Generalized or circumscribed absence of hair at birth, fol- 
lowed in later life by a normal hair-development. This condition is 
believed by writers to be due to pre-existing intra-uterine disease or 

Fig. 195. 




Alopecia congenita. 

to such a disease seriously involving the hair-pouches at birth, result- 
ing in a true alopecia, evidences of which may be wanting at the date 
of first examination by the physician. Thus some cases of congenital 
hair-absence are recorded as due to alopecia areata, to intra-uterine 
nervous shock, etc. 

5. Cases in which one or all of the anomalies cited above coexist 
with anomalous conditions recognized in the teeth, nails, and other 
organs. 

Dubreuilh and Petges 1 in a valuable paper on the subject of 
circumscribed congenital alopecia have discriminated between the 
following varieties : 

1. Circumscribed congenital alopecia, occurring upon a portion 
of the body chiefly the scalp, where there has been a congenital nsevus 
either actively developed or in the process of involution. 

The naevus may simply cover the area in continuity with the 
patch of alopecia, though possibly separated by an interval of sound 
skin. Usually in these subjects, nsevi are found elsewhere on the 
body. In these cases the outline of the patch is irregular with brown- 
ish or oval borders, the plaque being slightly elevated, even mamelon- 
mated, dark colored or pigmented, and sometimes covered with a 
downy growth of hair. 

1 Annales, 1908, s. iv., ix., p. 17. 



ALOPECIA CONGENITA. 957 

2. Circumscribed congenital alopecia, resulting from arrested de- 
velopment of the skin. In these cases, the plaques are simply situ- 
ated near the posterior fontanelle, over the occiput, or on or near the 
median line. There is usually no downy growth, no atrophy of the 
skin, and sometimes non-elevation of the surface. 

3. " Obstetrical " alopecia, characterized by irregular and vari- 
able outline of the patch, the skin being thin and not provided with a 
downy growth over a relatively large area occupying the parietal or 
fronto-parietal regions, where the forceps of the obstetrician are 
applied. 

4. " Sutural " alopecia, produced by enlargement of the cranium 
before union of the bones, its seat coinciding with the lines of the 
union of the cranial bones. There is adherence of the scalp to the 
cranial layers and a few normal hairs irregularly situated. 

The anomalies thus described are rare, the rarest being those in 
which there is failure of development of the hair-pouches, congenital, 
complete, and permanent. 

The absence of hair may be limited to one, several, or all regions 
of the body including the scalp, brows, axilla, and pubes, and the 
general surface normally provided with hair. The " complete and 
absolute cases " of the sort described by Eshner, Schede and Ziegler, 
are extreme divergencies from the average and due either to non- 
development of the hair-pouches or intra-uterine atrophy. 

The Australian races described as hairless seem to have included 
merely groups of aborigines of that country some members of which 
only are completely destitute of hairs. It is noteworthy that in some 
of these cases improvement has occurred under treatment. 

In cases commonly recorded under the titles given above, the mem- 
bers of one family or generations of a single family may be similarly 
affected; parents and child, grandparents and uncles, cousins 
and cousins-german, and other near or slightly removed relations of 
the subject of the anomaly may exhibit both natal and post-natal 
hypotrichiasis. ISTicolle and Halipre report the existence of this 
anomaly in thirty-six individuals occurring in six generations. 

The teeth and nails are frequently altered in cases of congenital 
alopecia. The teeth may be changed in every gradation from that in 
which there are few, defective, oddly arranged or shaped, or doubly 
ranked teeth, to the point of complete edentulism. When but three 
or four teeth are present, these are usually molars of the lower jaw, 
the incisors and canines being absent. It is probable that defects of 
the nails are somewhat more common than associated defects of the 
teeth, though accurate statistics are wanting. The number of male 
subjects presenting these anomalies is nearly double that of the 
female sex. In a record of fifty-eight cases where the sex of the 
subject is given, it appears that thirty-eight were males and eighteen 
females. 

Other abnormal conditions associated with atrichia and hypo- 



958 DISORDERS OF THE APPENDAGES. 

trichiasis are recognized in those who have abolished or defective 
secretions, who do not sweat, who shed no tears, who have impaired 
sense of smell and taste, and who are not provided with mammary 
glands. We have reported a case in which there was coincident web- 
bing of the fingers and of the toes with citation of a similar case ob- 
served by Dr. Winfield, of Brooklyn. Several of the subjects of the 
anomalies are reported as victims of alopecia areata, atrophy of the 
finger tips, hereditary epidermolysis bullosa, and xeroderma. In a 
small group of cases, two observed by myself, whitish mosaic-like 
areas have been recognized in the retina supposed to be due to 
retinitis albicans, but more probably the result of congenital rever- 
sion, the type of some of the lower animals whose retinas exhibit 
areas through which the sclerotic is projected. 

Etiology. — The anomaly is probably due to failure of development 
of the hair-pouch from the epiblast. The disorder is not contagious ; 
no microbe has been recognized as effective in its production. The 
mothers of some of the subjects of the anomaly have suffered from 
ante-natal alopecia areata. 

Pathology. — In some instances blind sebaceous glands and hair- 
pouches have been recognized ; in others there has been failure of 
development of the hair-pouches. According to Schede, Atkins, and 
Ziegler, the sebaceous and sudoriparous glands are normal but in the 
derma epithelial cylinders can be recognized composed of five or six 
layers of cells with a central lumen but destitute of hair-papilla and 
the hair itself. These are supposed to represent hair-sheaths incom- 
petent to produce evolution of the pilary filament. Brocq, represent- 
ing his colleagues in France, sets down among the forms of con- 
genital alopecia consecutive to pathological processes those conditions 
in which there are hair-nodes (pili annulati, trichonodosis, monile- 
thrix, aplasie moniliforme ou intermittente des cheveux). These are 
conditions in which after the birth-hair is shed, the filaments pro- 
duced later are sparse, short, fragile, and more or less checkered 
along the shaft into the nodosities and narrowings characteristic of 
trichonodosis. Most of the subjects of the disorder are affected with 
keratosis pilaris. 

Treatment. — The treatment of these conditions is that which should 
be employed in cases of alopecia simplex. 

Prognosis. — It is to be remembered that many of these cases are 
hopeless, the hairs never developing to a normal condition, the nails 
always undeveloped, and in some cases the teeth permanently deficient 
in number and size. 

ALOPECIA PREMATURA. 

Premature or presenile alopecia (premature calvities) is that form 
of acquired baldness which occurs in individuals who have not at- 
tained advanced years. Idiopathic and symptomatic forms are recog- 
nized by writers, though it is probable that a definite cause exists for 
cases occurring in individuals under forty-five years of age. 



ALOPECIA PREMATURA. 959 

The idiopathic variety does not originate in the diseases of the 
scalp or of the general economy that are recognized as effective in the 
production of other forms of baldness. In many cases, however, 
classed as idiopathic a careful search will reveal the presence of a 
seborrhea. It is, as with senile alopecia, more common in men than 
in women, and is in the former sex decidedly prevalent among those 
leading sedentary lives. The loss of hair may be produced either 
rapidly, or, more commonly, slowly, and at any period after the 
puberal epoch. It is always symmetrical and at times remediless, 
partial calvities being the permanent result of the process. The 
pilary growth may recede gradually and evenly from the forehead, or, 
what is more frequent, recede from the temples on either side of the 
median line, leaving a more vigorous crop extending centrally toward 
the root of the nose, or produce the effect of the tonsure described 
above. In many families there is a predisposition to this premature 
loss of hair, usually in the form of the receding temple, that may be 
recognized in the males of succeeding generations. 

The process may begin with slight thinning of the hairs in the 
affected regions as the result of loss of the pilary filaments, but on 
close examination it becomes clear that the hairs which remain are 
relatively lustreless, and lacking both in vigor and in size as com- 
pared with the hairs growing on unaffected portions of the scalp. 
Often the fall of individual hairs is followed by a new growth of 
younger filaments, these rarely developing beyond the grade of short 
and slender hairs which either soon disappear or persist without much 
further development. It is noticeable that the ensuing loss (usually 
very gradual, occasionally rapid as a consequence of changes in 
the bodily health) may be associated with the growth of strong 
and actively growing hairs over unaffected regions (occiput, bearded 
face, pubes, etc.). In some persons the baldness, even before the 
attainment of the middle of the third decade, involves the greater 
part of the scalp. 

The obvious causes are assigned different weight by different au- 
thors, inherited tendencies playing an important part. In-door occu- 
pations, such as are the lot of the professional classes, counting-room 
workers, etc., and the wearing of stiff hats which operate not merely 
by exclusion of sunlight and air, but also by constriction of the scalp 
about the temples, are largely responsible for the result. The claim 
that daily application of water to the scalp is a cause of baldness is 
ill-founded. Many individuals who have indulged regularly in the 
practice for years have exhibited a luxuriant growth of hair on the 
scalp even in old age ; and the animals not aquatic, whose education or 
instincts have led to very frequent immersion of the skin in water 
are not known to suffer from induced alopecia, though it is well 
known some of the domesticated animals suffer largely from alopecia 
due to other causes (errors in diet, artificial habits as respects hous- 
ing, etc.). 



960 DISOBDEBS OF THE APPENDAGES. 

Symptomatic Presenile Alopecia may result from a number 
of systemic and local conditions. Loss of hair (Defluvium Capil- 
lorum) is common after typhoid, eruptive, and other fevers, and 
after other local and systemic disorders interfering with the nu- 
trition of the scalp. Frequently the hairs do not fall for some weeks 
after the patient has recovered from the constitutional disturbance, 
but remain in their follicles until pushed out by the new hairs, or 
until gradually pulled out by the use of brush and comb. In these 
cases there is usually a general and symmetrical thinning of the hair. 
The loss is not often permanent, as new hair gradually replaces that 
which has fallen. The alopecia of the early periods of syphilis is of 
this order, but occurs in characteristic patches. A slower loss of hair 
is seen in many cachectic conditions such as tuberculosis, diabetes, 
leprosy (in which the alopecia is limited often to the eyebrows and 
eyelids), and myxcedema. 

ALOPECIA FURFURACEA. 

Of all the local causes of alopecia, seborrhcea (q. v.) in some form 
is the most frequent, 1 the condition produced being variously desig- 
nated as Alopecia Furfuracea, Pityriasis Capitis, Alopecia Pityrodes 
Capillitii. Loss of hair varying from moderate thinning of the 
growth to considerable symmetrical baldness, usually of the vertex, 
accompanies the pityriasic forms of seborrhoea or eczema sebor- 
rhoeicum of the scalp. The affection is exceedingly common, espe- 
cially in men. 

The disorder, essentially chronic in course, may be gradual or 
relatively rapid of occurrence. L^sually it is manifested first in early 
adult life, though persons of both sexes, from twelve to fifteen years 
of age, may at these ages display typical forms of the disease. After 
the condition known as Dandruff has existed for some months or 
years the subject of the affection discovers a relatively large loss of 
hair from the scalp, producing thinness of the growth upon the ver- 
tex, near the brow, or over the temples. The hairs, when examined 
in situ upon the scalp, are shortened, dry, harsh, lustreless, and rarely 
well anointed with sebum. They are rebellious to comb and brush, 
and project irregularly from the brushed surface. Those shed from 
the scalp, especially of men, are found to be nearer in type to the 
lanugo- or downy hairs than those which fall physiologically from a 
vigorous growth of hair in a healthy subject; that is, they are short, 
thin, pointed, and often with an indistinct medulla. 

At the same time the scalp is in process of incessant desquama- 
tion, the scales usually being of pityriasic type, and exceedingly abun- 
dant so long as the alopecia is not complete, after which the epidermal 
catarrh soon disappears. The mealy, bran-like scales are shed in a 
fine shower upon the clothing of the patient, and, the disease being 

1 Of 300 cases of premature alopecia, Jackson (J. C. D., 1900, xviii., p. 352) 
found 75 per cent, due to seborrhoea. Elliot (N. Y. Med. Jour., 1895, lxii., p. 
525) states that of 346 cases over 90 per cent, were due to this cause. 



ALOPECIA SENILIS. 961 

more common in men than in women, its traces are often distinct 
upon the collar of the coat after the fingers have been passed through 
the hair. The same flour-like, whitish and grayish scales are distinct 
and plentiful among the hairs to which they cling, and they can also 
be recognized over the scalp-surface when the latter is inspected with 
care. Itching is often marked ; the scalp may be scratched and torn 
by the nails, and is, in some cases, reddened and thickened. The 
condition is prone, sooner or later, to develop the severer phases of 
seborrhoea and dermatitis seborrheica. 

Other local causes of alopecia are found in various inflammatory 
disorders of the scalp, such as psoriasis, eczema, etc. ; in morphoea, 
lichen atrophicus, and lupus erythematosus ; in syphilitic, tubercular, 
and other destructive lesions; in some forms of folliculitis (consid- 
ered in the succeeding pages) in which the follicle and surrounding 
tissue are destroyed by suppuration; in ringworm, favus, and other 
parasitic affections of the scalp ; in traumatism, which may occur as 
a bruise or be the result of scratching or rubbing; after drug inges- 
tion (thallium acetate) ; and after exposure to the x-rays. 

The forms of alopecia described above as encountered upon the 
scalp may involve also other hairy portions of the body, as of the 
axillae and the pnbes; and these also in variable degrees. 

ALOPECIA SENILIS. 

The senile condition is by no means a synonym for baldness. 
Many men of advanced years are vigorous, and have no loss of 
hair on the scalp, an abundant pilary growth, grayish and at 
times silvery-white, covering the cranial surface. The baldness occur- 
ring in old age, whether upon the vertex so as to produce a tonsure 
like that of the priest, or whether limited to the frontal region, or so 
extensive as to involve nearly the entire calvarium leaving a fringe 
of hairs at the occiput and temples merely, is always remarkable for 
its symmetry. There is, hence, a certain degree of dignity added to 
the appearance of the head that an asymmetrical loss of hair does 
not produce. It may occur at varying ages of advanced life, and is 
frequently traceable to an early seborrhoea sicca. It is much com- 
moner in men than in women, largely because of the difference in 
the manner of covering the head in the two sexes, women usually 
wearing an exceedingly light dress for the head, while men encase 
the latter with tight-fitting caps or hats which interfere with proper 
aeration of the scalp. Individuals of the male sex, also, in conse- 
quence of wearing the hair short, bestow far less time upon the care 
and dressing of it. In uncivilized races these differences are less 
marked, men pay great attention to the ornamentation of the scalp, 
and senile baldness is of less frequent occurrence. 

The bald surface, as a rule, is smooth and shining, the atrophy of 
the pilary system corresponding to that noticeable in other structures 
of the aged; it is occasionally the seat of a seborrhoea oleosa. The 

61 



962 DI SOB •DEES OF THE APPENDAGES. 

hair-follicle, with its accessory sebaceous glands and occasionally the 
skin itself, are often in a state of atrophy, though there may be dila- 
tation of the sebaceous glands. There is commonly blanching of the 
hairs, which are shed gradually, as also of those which remain, 
though the canities is not constant. This condition is much less fre- 
quent upon the surface covered by the beard and pubic and axillary 
hairs, where according to Michelson, the hairs in advanced years are 
often denser than at other periods of life. 

Etiology and Pathology of the Alopecias in General. 1 — The 

causes of congenital alopecia are not known. In some cases it is an 
expression of reversion to type. Senile alopecia is attributed by many 
to the general atrophic changes which take place in the aged. This 
atrophy evidently will not explain the cases, often classed as senile 
alopecia, occurring in men under sixty or seventy who are in all other 
respects vigorous. The hair-loss in systemic conditions is due largely 
to defective innervation and nutrition of the scalp. Those due to 
trauma, to the presence of vegetable parasites, and to destructive 
agents of any sort, are explained readily. 

There remain numerous cases of idiopathic alopecia the causes 
of which are obscure or differently interpreted by different observers. 
Those associated with seborrhoeal flux are explained by Unna on the 
basis of the morococcus recognized by him ; while Sabouraud assigns 
as the chief factor for many forms the seborrhoeal micro-bacillus dis- 
covered by him, pointed at both ends, minute, colorless, increasing 
by division in twos, forming thus chains, congregating in enormous 
numbers in the hair-follicle below the epiderm, and where the seba- 
ceous gland joins it. By injection of a pure culture, a rabbit was 
made bald in 40 days. 

According to the same author, the bacillus responsible for the re- 
sult produces first an irritative effect in the horny layer of the skin 
with the result of forming a " cocoon " agglutinated to one side of the 
pilary shaft. Then follow: sebaceous flux, hypertrophy of the seba- 
ceous gland, atrophy of the hair-papilla; and gradually thereafter 
pigment-failure, absence of medullary cells, thinning of the filament, 
its substitution by a dwarfed hair, and eventually calvities. 

Round and oval spores have also been described by Melassez 
(1874) as existing both in the hair-pouches arid in the neighboring 
horny layers of the scalp. 

1 Literature : Bettmarm, Tiber experimentelle Alopecie, Verhandlungen des V. 
internat. dermatolog. Krongesses, Bd. ii. Buschke, A., Experiment eller Beitrag 
zur Kenntnis der Alopecie, Berl. klin. Wochenschr., No. 53, 1900. Idem, Uber 
experimentelle Erzeugung von Alopecie durch Thalium. Verhandlg. der Deutschen 
dermat., Gesellschaft, 1901. Idem, Weitere experimentelle Untersuchungen uber 
Alopecie und die Lokalisation von Hautkrankheiten, Berl. klin. Woch., No. 39, 
1903. Sabouraud, Traitement des teignes tondantes, La Prat, derm., t. iv. 
Combemale, Echo medical du Nord, 27 Febr., 1898. Jeanselme, Soc. de Derm., 
Nov. 10, 1898. Guinard, Journ. des Practic, Nov. 26, 1898. Hallopeau et Laf- 
fitte, Soc. de dermatologie, 1899. Giovannini, Dermat. Zeitschr., Dec, 1899. 
Vassaux, These de Paris, 1898, L 'acetate de thallium en therapeutique. Vignolo 
Lutati, Giorn. ital, 1905; Nobl, Archiv, 1906, lxxviii., 113. 



ALOPECIA. 963 

The views of none of the observers and experimenters who have 
devoted an enormous amount of skill and energy to this work have 
achieved general acceptance. One of the chief objections to such 
acceptance rests upon the fact that the complete clinical picture of 
seborrhoi'c and other forms of alopecia has never been reproduced 
artificially either upon man or animals. 

Alopecia has been explained by a number of writers as due to 
toxines elaborated in the system. Parker, for example, has separated 
from expired air a " trichotoxicon," believed to originate in the 
residual air left in the upper portion of the lungs in men living a 
sedentary life. With the product obtained this author seems to have 
induced alopecia in pigeons. Meyer believes that the intestinal tract 
furnishes a similar toxic agent. 

Experiments have been conducted by Carlo, Buschke, ISTobi, and 
others showing that the acetate of thallium produces in the lower 
animals systemic effects, even in cases lethal, with partial and in 
some cases total baldness. The applications were made externally in 
the strength of one to six in vaseline or traumaticine ; the salt was 
also injected subcutaneously. By reducing the strength of the salt in 
man, thallium alopecia has been advocated as an effective measure, 
not as yet wholly without danger, in removing hair from the skin in 
some of the disorders due to the vegetable parasites. The application 
of cantharidin has produced a similar extensive baldness (Baston). 

Treatment. — In alopecia the underlying conditions, local or sys- 
temic, must be treated by measures appropriate to each case. Elliott, 
Jackson, Kreuzfuchs, and others call attention to the great importance 
of prophylaxis. Early and persistent scalp massage, permitting the 
hair to grow at some length as in the case of women who preserve 
the hair as a rule better than men, and wearing of loosely fitting head- 
coverings are of value. The Christ-Church Hospital boys of London, 
who never wear hats, are remarkable for the thickness and vigor of the 
hair of the head. The naked negroes of Africa, men and women alike, 
who use their hair for protection from the tropical sun, have superb 
(however filthy) coils of hair covering the head. If the head of man 
were never artificially covered, it is probable that there would be no 
baldness save that produced by a distinct disease of the scalp. The 
use of brushes and combs in common by members of one family is to 
be forbidden. The same rule applies to these utensils in hotels, 
parlor-cars, public resorts of all kinds, and hair-dressing establish- 
ments. Respecting the covering of the scalp with hats, writers have 
called attention, first, to the consequent exclusion of light and air; 
second, to pressure upon the circlet above the ears and about the 
temples whereby the vascular supply of the vertex is impeded (it is 
here and over the temples where the thinning of the hair commonly 
becomes first apparent) ; third, to the consequent hypersecretion of 
sweat (Meyer). 

In the management of alopecia the general health should always 



964 DISORDEBS OF THE APPENDAGES. 

be considered, and any condition interfering with the nutrition of the 
scalp and hair should he removed. Cod-liver oil, the ferruginous 
tonics, and the hypophosphites, are indicated in many cases. The 
distaste for fats shown by certain victims of alopecia furnishes an 
indication in their systematic management. 

The following general considerations are worthy of attention in 
many cases: Massage of the scalp, practiced by the fingers once or 
twice daily in such a manner as to influence the subdermal struc- 
tures, is useful. A pillow filled with hair or other equally firm ma- 
terial, should be preferred to the feather pillows in common use, and 
in which the scalp is often too warmly and too deeply cushioned. In 
the case of women the wearing of artificial hair should be interdicted ; 
as well as the use of the " crimping-iron " and the curl-paper. Sharp 
hat- and hair-pins thrust deeply between the hairs are often a source 
of serious damage. In all patients the access of sunlight and fresh 
air is needful for the vigor of the hairs of the scalp. Disuse of the 
brush and preference for the comb in arranging the hairs on the 
head of women are responsible for the hair-loss in many instances. 
Every scalp from which the hairs are falling requires daily, gentle, 
systematic friction with a hair-brush the bristles of which penetrate 
to the scalp-surface and stimulate gently without wounding or irri- 
tating. Faradization and electricity being as a rule less systematic- 
ally available, may be regarded as useful adjuvants in the hands of 
the expert. Singeing the hairs is without question harmful. The hat 
should be light, and well ventilated, and worn as little as possible. 

Local treatment is of importance in nearly all cases, and in gen- 
eral is directed toward stimulating the nutrition of the hair-follicle by 
producing in its periphery a species of transitory and artificial hyper- 
emia. This result is accomplished by the local employment of one 
or more of the alcoholic, oily, alkaline, and other stimulating appli- 
cations described below. 

Local treatment may often be preceded by shampooing with either 
the Sarg fluid soap or combinations of glycerin, alcohol, and sapo 
viridis (tincture of green soap) ; or with eggs to meet the require- 
ments of individual cases. The shampooing may be practised every 
few days, once in the' week, or once every two or three weeks, accord- 
ing to the needs of each case. The scalp after all such shampooings 
should be anointed with lanolin, plain or salicylated ; vaselin ; equal 
parts of lanolin, glycerin, and rose-water; the oil of benne; or 
scented castor-oil. In obstinate cases the nail-brush may be used 
vigorously over insensitive scalps at the time of shampooing. 
The ointment-bases named above may often be medicated advan- 
tageously with sulphur, resorcin, chrysarobin, tar, cantharides, or 
mercury. Instead of ointments, lotions containing cantharides, car- 
bolic acid, capsicum, resorcin, mercuric chloride, ammonia, or nux 
vomica may be used. Care should be taken to avoid unpleasant 
staining or dyeing of the hair by both resorcin and chrysarobin. 



ALOPECIA. 



965 



The former should never be compounded with ammonia. Formulae 
for lotions and salves to be used in this way are appended : 



Hydrarg. chlorid. corros. 
Spts. vin. rectif., 
Acid. acet. dil., 
Glycerin., 
Aq. ros., 

Hydrarg. bichlorid., 
Tinct. cantharid., 
01. amygdal. dulc, 
Spts. rosmarin., 
Spts. vin. rect., 
Aq. destill., 



Sulphur, prseeipit., 
Lanolin. 
Glycerin. 
Aq. rosae, 



tin., L 
)sse, j 



Hydrarg. chlorid. mit. 
Hydrarg. amnion., 
Vaselin., 



Kesorcin., 

Quinini (alkaloid). 
01. rieini, 
Alcohol., 



]£ Cantharid. tinct., 
Capsici tinct., 
Spts. vin. rect., 
Aq. ros., 



gr. v; 

$y; 

3ij; 

3 V J; 

gr- iij ; 

3ss; 
3j; 

3J; 

q. s. ad 3vj 



60 1 



15 
180 



|33 



3j; 
aa 3ijs 



3iv; 

ad 5J ; 



15 
4 
30 
60 
q. s. ad 180 

4| 
aa 101 



M. 



5 

2 

ad 30 



33 



M. 



[Bronson.] 



3j; 4| 

gr. xv; 1| 

TTlx-xxx; 1 66-2 

ad Jiv; ad 128 1 M. 

[Stelwagon.] 



3ij; 

3Jss; 
ad §v; 



81 

1| 

45 

ad 1501 



M. 



Where the hair is unusually dry, Saalfeld employs : 

gr. xv ; 



I£ Tannobromini, 
Bals. Peruv., 
Adipis colli equini, 

Richema and Staganovitch advise: 



ad ji: 



1| 

2| 
301 



^ Acid, lactic, 3ii-iv; 8-16 

Spirits, vin. rect., ^j ; 30 

A q- ros v B\i; 30 M. 

To be applied with absorbent cotton, using friction until the surface is 
reddened. 

Roussel advocates the hyposulphite of sodium in 25 per cent, 
solution. 

Walsh advocates : Lysol, one part ; alcohol, eight parts ; and rose- 
water, 25 parts, adding cantharides if desired. He also recommends 
a lotion composed of: 



Acid, salicylic, 


3iij; 


12| 


Acid, carbolici, 


3.i; 


41 


Olei rieini, 


3ii.i; 


12) 


Spts. vin. rectif., 


q. s. ad ^vi ; 


180| M 



966 



DISOEDEES OF THE APPENDAGES. 



The addition of acetic acid to a scalp-lotion seems to favor pene- 
tration of other remedies. Pilocarpine hypodermatically has given 
good results. Further suggestions regarding the details of treatment 
of alopecia, and the special remedies recommended for alopecia fur- 
furacea, are given under Seborrhcea. 

Prognosis. — Congenital, senile, and many of the so-called pre- 
senile idiopathic alopecias are practically remediless, though in all 
forms further loss of hair often can be prevented or greatly retarded 
by proper treatment. The symptomatic alopecias in which there is 
destruction of the hair-follicle, as in lupus erythematosus, syphilitic 
ulcers, favus, and some forms of folliculitis, are permanent ; those due 
to systemic disorders and to local inflammations are usually tem- 
porary. In alopecia due to seborrhcea persistent treatment will pre- 
vent further loss of hair, and in recent cases may produce a new 
growth. 

ALOPECIA AREATA. 1 

(Lat.. area, a vacant space [arere, to whiten, Fox].) 

(Porrigo Decalvaxs, Tinea Decalvaxs, Area Celsi, Area 

JoHNSTOisri, Alopecia Circumscripta. Fi\, Pelade.) 

Symptoms. — Alopecia areata is a disorder affecting the hairy sur- 
faces of the body, often limited to the scalp but at times generalized, 
characterized at the outset by the occurrence of one or several, circum- 





Fig. 196. 










\ 




■L. 


M J 


^^HMMfc^ 


*% g &**A 





Alopecia areata. 



scribed, round or oval areas completely destitute of hair and exhibit- 
ing few if any other changes in the part affected. Crocker makes an 
etiological classification of these cases, assigning to a first class the 

1 For bibliography, see Dehn. La Pratique Dermatologique, t. iii., p. 647. 



ALOPECIA AREATA. 



967 



" universal " forms ; to a second the local or neurotic forms ; to a 
third the parasitic forms, " true alopecia areata " ; and to a fourth the 
circinate seborrhoic forms. 

The hair-loss is limited usually to the scalp, but may occur upon 
the beard, the genitalia, axillae, brows, eyelids, and the general surface 
of the body. Cases occur, especially in early childhood, in which the 
closest scrutiny with a glass fails to detect a single filament of hair 
upon any portion of the skin.. 

The disease commonly manifests itself by the sudden and com- 
plete loss of hair over a circinate, circumscribed patch, usually upon 
one side of the scalp, so rapidly effected that a first discovery of the 

Fig. 197. 




Alopecia areata. 



fact may be made at the toilet of the morning. Occasionally vague 
neurotic sensations precede the hair-loss. In yet other cases the loss 
of hair is gradual, the patch attaining large dimensions in the course 
of two or three weeks. Less frequently an area of baldness will con- 
tinue to extend peripherally for many weeks. Instead of one area, 
there commonly are several, which may develop simultaneously or at 
varying intervals. 

The patches may be round, oval, circinate, or irregularly shaped, 
and may vary in size from that of a small coin upward. They may 
be so numerous as to disfigure the entire scalp, and though they 
touch at the borders they can scarcely be said to coalesce, as the 
individual areas are usually recognizable. Extension, however, may 
occur by coalescence of patches, as well as by development of the area 
of a single patch.. Their surface is smooth, soft, whitish, and usually 
destitute of hairs. The affected scalp may be thinner and more lax 



968 DISORDEES OF THE APPENDAGES. 

than normal, and often is depressed slightly below the level of the 
surrounding skin, but in rare instances it is tumid and slightly red- 
dened. As a rule, there are no subjective sensations, though the 
affected areas may be the seat of slight pruritus, or of anaesthesia, 
and are nearly always less sensitive to irritating applications than 
the surrounding normal parts. 

The hairs at the periphery of patches that have attained their 
full development are normal in every way, and are firmly implanted 
in their follicles, but at the borders of areas which are still spreading 
the hairs are loose and fragile, often broken off near the surface, thus 
leaving short stumps which exhibit at the bulb a spade-like extremity 



Fig. 


198. 


B -* 




»ifc » 




^^l 





Fig. 199. 




Alopecia areata. 



Alopecia areata. 



or an attenuated point, the non-atrophied shaft thus contrasting with 
the wasted portion implanted below the cutaneous level. Crocker 
likens their shape to that of the exclamation-point. Newly formed 
areas may be covered in greater or less degree with these character- 
istic hairs, which, however, soon fall out. 

The course of the disease is variable ; it may persist for months or 
years without apparent change ; or new patches may form while 
those of an older date gradually regain wholly or in part the pilary 
growth which, however, may be lost repeatedly in the same area. 
Shifting areas of baldness may in this manner invade the entire sur- 
face of the scalp, which yet at any one moment of time exhibits a 
loss of but part of its hirsute covering. 

When the filaments begin to reappear there is commonly a fine 
downy growth over the affected area, later replaced by a crop of 
thicker and stronger whitish filaments, which are always succeeded, in 
cases terminating favorably, by a growth of hairs as well colored, as 
vigorous, and as persistent as any which were at first lost. An odd 
appearance is often presented by patients who are improving, when 



ALOPECIA ABE AT A. 969 

the young and white new hairs contrast vividly with the dark shade 
of those on the unaffected scalp. 

This disorder, which is more common than is generally believed 
bv physicians, may, in some cases, at its outset be preceded or be ac- 
companied by symptoms of ill health, such as headache, malaise, 
inappetence, loss of flesh, or malnutrition. In other cases, cephal- 
algia, paresthesia, pruritus, and formication of the skin of the scalp 
and other regions indicate disturbance of the nervous centres. Often, 
however, patients of this class are in sound health. 

Among the unusual features of the disease may be mentioned the 
occurrence of alopecia in bands or streaks ; at the site of an injury or 
along the course of a nerve; or over the entire body, removing even 
the finest lanugo-hairs. Universal alopecia may occur suddenly, or as 
the result of a gradual thinning of the hair, or may follow the 
existence of the disease in characteristic areas. This variety of alo- 
pecia, which is fortunately rare, usually occurs after the middle 
period of life, but it may develop in the very young. 

Odd-looking effects are produced when in the course of the dis- 
ease with and without the development of patches in the scalp, the 
half of a moustache on one side of the face falls, or the hairs of one 
eyebrow or one eyelid ; or even when all the hairs are lost from both 
brows and lids of each side of the face. 

In some instances alopecia areata is associated with other cu- 
taneous diseases. It is not rare to discover patches which are also the 
seat of the vegetable parasites. A male patient, long psoriatic, under 
our observation exhibited a typical seborrhoea capitis, and later de- 
veloped a no less typical alopecia areata. Cases associated with 
vitiligo are reported by Besnier, Duhring, Freeland, DuCastel, and 
others. Coincident dystrophy of the nails has been observed by 
Darier and Le Sourd, 1 Crocker, G. H. Fox, 2 and others. Other con- 
ditions reported as associated with alopecia areata are scleroderma, 
thyroid disease, and moniliform hair (Walsh) , 3 syphilitic affections, 4 
of the same part, dermatitis, and folliculitis. 

The course of the disease in young subjects is usually toward a 
favorable result. There is hope, as a rule, when even the downiest 
and thinnest growth, requiring a good light and a glass for its recog- 
nition, can be appreciated. Even when so feebly attached that these 
filaments are removed with ease by the fingers or a brush, and when 
they spontaneously fall they may be replaced by crop succeeding crop 
of stronger filaments, which eventually persist. In serious cases, 
usually after the forty-fifth year of" life, and in those of long standing, 
there may result atrophy of the hair-follicles and a resulting remedi- 
less baldness. 

There is reason for believing that the disease has a stadium of 

1 Annates, 1898, s. iii., ix., p. 1009. 

2 J. C. D., 1902, xx., p. 574. 

3 Brit. Med. Jour., 1902, i., pp. 812, 883. 

4 See Morrow's Case, J. C. D., 1902, xx., p. 275. 



970 DISOEDEES OF THE APPENDAGES. 

evolution and involution, though its exact limits are not known. 
Few individuals fully recover the hair in less than one year. The 
majority attain the desired end within a period of two years. These 
limitations, however, apply to the asymmetrical forms of the dis- 
ease in the relatively young. The symmetrical alopecia areata of the 
middle-aged is a far more formidable affection, though in some of 
these cases, when the loss is recent, proper treatment will restore the 
hair. 

Few diseases are the source of greater mental distress than those 
of the class under consideration. The fear that they will be sus- 
pected of having syphilis and the social ostracism which the de- 
formity entails produces a morbid mental state which is especially 
noticeable in nervous women. 

Mewborn 1 has introduced the term Tricho pathophobia to desig- 
nate the fear of disease of the hair. 

A rare form. Alopecia Circumscripta, seu Orbicularis, is described by 
Neumann in which the areas are much depressed, are the size of a 
pea or smaller, and are decidedly anaesthetic. The prognosis is 
unfavorable. 

Etiology. — In their modern acceptation, the words alopecia areata 
describe merely a loss of hair occurring at first in restricted areas 
which may become generalized and which without question may 
spring from various causes. The conflicting views of the nature of 
the disease have been concerned with the etiological factors supposed 
to be responsible for the results, and have demonstrated the fact of 
their multiplicity. It is unwise to-day to describe one form as " true " 
and another as spurious, simply on the ground of diversity of causes. 
Equally unfounded is an arrangement of the several clinical appear- 
ances into different forms of the disease because of a difference in 
their etiological relations. 

Alopecia areata occurs with equal proportion in the two sexes, 
rather more often in persons having dark than in those of light hair, 
and among these irrespective of social condition. Of the partial and 
asymmetrical forms, the larger number occur in young subjects, from 
childhood to early adult dife. The severe and generalized forms are 
encountered more often in middle-aged persons. In the latter class 
especially the disease is observed occasionally to follow the obscure 
disorders of the nervous centres due to sudden or prolonged undue 
excitation. Tn young subjects a peculiar repugnance to the ingestion 
of fat and meat may often be discovered. 

The neuropathic origin of a large number of cases (Alopecia 
Neurotica) is indisputable and verified in every clinical experience. 
Blows on the head, not rarely resulting in well-marked scars visible 
on careful inspection of the affected regions, nervous shock (fright, 
lightning-stroke, great and prolonged anxiety, grief), traumatism of 
other regions than the scalp-surface, prolonged and severe toil in 
close apartments, these again and again have produced typical clin- 

1 Jour. Am. Med. Ass., vol. 50, p. 19. 



ALOPECIA ABE AT A. 971 

ical symptoms of the disease. Max Joseph. 1 produced baldness in the 
ears of cats and rabbits by excision of the second cervical ganglion. 
Jacquet 2 finds that alopecia areata is associated frequently with de- 
fective teeth or other sources of irritation of the cutaneous nerves. 
The coexistence of well-marked alopecia areata with changes in the 
hails, with the symptoms of Graves' disease, and in particular in 
young women with cessation of the menstrual flux which is restored 
when the bald areas became covered with hair, all point to the 
nervous origin of many cases. Crocker states that 90 per cent, of 
all cases with complete denudation of an affected area are due to 
parasitic disease, but this ratio certainly does not hold good for even 
the average of patients seen in America. 

The coexistence of alopecia areata and other affections of the in- 
vaded surface is noteworthy and suggests the possibility of etiological 
relations. 

The parasite described by Sabouraud and those recognized by 
other observers have been claimed to be the effective cause of the 
disease, and this view is supported for a special class of cases by the 
evidence furnished where several instances of the disease have oc- 
curred in one family and in particular by the prevalence of so-called 
" epidemics " of the disease in public institutions, such as have been 
reported in this country by Bo wen 3 and Putnam, 4 and also in 
France, Germany, and elsewhere. It is to be noted, however, that few 
of the cases reported as occurring in epidemic form have been illus- 
trations of the disease in typical manifestations. In yet other in- 
stances in which there are good clinical evidences of contagion, it is 
impossible to deny that a strong case is made out in favor of the 
parasitic origin of the malady and the possibility of its extension by 
transmission of a germ from one individual to another. ]STo classical 
reproduction, however, of alopecia areata has yet resulted from in- 
fection of the sound skin with pure cultures of any of the parasites 
claimed as effective. 

Pathology. — The anatomical lesions in alopecia areata have not 
been determined definitely. The hairs fallen from the surface, when 
examined with the microscope, are seen to be atrophied in bulb and 
shaft, as in other forms of alopecia. Fracture of the shaft is in some 
cases also noted, evidently an accident of the process. 

As a result of careful examination of many pathological sections, 
Giovannini 5 and Bobinson 6 believe the disease is primarily an inflam- 
mation of circumscribed areas of the corium, and especially of the 
subpapillary layer. In a small patch of one week's duration Bobin- 
son found marked perivascular cell-infiltration in a limited region of 

1 Monatshefte, 1886, v., p. 483. 

2 Aimales, 1902, s. iv., iii., p. 97; see also Tremoliers, Presse med., 1902, liv., 
p. 576. 

3 J. C. D., 1899, xvii., p. 400. 
* Arch, of Pediat., 1892, ix., p. 595. 
s Aimales, 1891, s. iii., ii., p. 921. 
6 Morrow 's System, vol. iii., p. 865. 



972 DISOBDEBS OF THE APPENDAGES. 

the coriurn, the papillse being but mildly affected, while the epi- 
thelium, rete, subcutaneous tissue, and glands were normal. Some 
of the hair-follicles were normal, while in others no papillse could be 
found, and the hairs were wanting or imperfect. In cases of longer 
standing evidences of inflammation were more marked and extensive, 
and there were vessels with thickened walls and narrowed lumina. 
In some cases there was more or less atrophy of all elements of the 
corium, with destruction of the hair-follicles and sebaceous glands. 
Giovannini, who describes an invasion by leucocytes of the hair- 
follicle, considers the process a deep-seated folliculitis. 

Eichhorst, 1 Thin, 2 v. Schlen, 3 Robinson, 4 Bowen and others dis- 
covered in affected patches and about the bulbs of hairs in alopecia 
areata microorganisms which were cultivated in generations, but 
which were not shown to be effective in the production of the disease 
de novo. In a series of three hundred cases Sabouraud 5 found in the 
early stages of the disease a micro-bacillus. He obtained pure cul- 
tures, with which he produced typical areas in calves, rabbits, and 
guinea-pigs. He finds the same bacillus in comedo, acne, and sebor- 
rhcea, and believes that alopecia areata is an acute form of seborrhoea 
oleosa. 

He finds constantly in the early stages large numbers of his 
micro-bacillus surrounded by keratinized epithelium, forming a 
cocoon-shaped mass which occupied the much dilated follicle-neck. 
In the later stages of the disease he finds no bacilli, but describes 
inflammatory changes, atrophy of the follicle, and achromia of the 
basal layer, all of which he ascribes to the influence of local toxines. 
Walker and Rockwell found that in the majority of 63 cases ex- 
amined by them, the hairs were sheathed with staphylococcus epi- 
dermidis albus (Welch) and there was coexistent seborrhoea. 

Diagnosis. — Alopecia areata is to be distinguished from vitiligo of 
the hairy portions of the surface by the preservation of the pilary 
growth in the disease last named, the filaments, moreover, having 
usually a blanched and whitened look, due to the absence of pigment. 

From ringworm and favus of the scalp the disease in question is 
differentiated by the suddenness of its onset; the absence of stumps 
of hairs, scales, crusts, and evidences of irritation in the involved 
area ; the whiteness, smoothness, and complete baldness of the latter ; 
and, above all, by the failure to detect with the microscope the evi- 
dence of the presence of a vegetable parasite. Ringworm and alopecia 
areata may coexist. In cases of so-called "bald-ringworm" the 
diagnosis must rest upon the microscopical findings. 

The asymmetrical patches of seborrhoea of the scalp are recognized 
by the presence of the fatty plates pasting the hairs to the scalp-sur- 
face, as well as by the slow and very gradual onset of the disorder. 

1 Virehow's Archiv, 1899, lxxviii., p. 197. 

2 Trans. Eoyal Soc, 1881-82, xxxiii., p. 247. 

3 Virehow's Archiv, 1885, xeiv., p. 327. 
* Morrow's System, vol. iii., p. 862. 

5 Annales, 1896, s. iii., vii., p. 253. 

6 Scottish Med. and Surg. Jour., 1901, viii., p. 12. 



ALOPECIA ABEATA. 973 

Other forms of baldness than those named above are all of gradual 
and, in their early stages, of symmetrical development. Those result- 
ing from traumatic injuries of the scalp with cicatricial results are 
easily determined as having such an origin. 

Treatment. — One necessarily views with distrust all treatment 
for that disease which in the course of months or years usually termi- 
nates in spontaneous recovery, and in the meantime may bid defiance 
to each and every therapeutic measure. Nevertheless, persistent and 
hopeful management of even apparently desperate cases is occasion- 
ally rewarded by such brilliant consequences that, however slight may 
be the foundation for a belief in the value of the therapy employed, 
it deserves recognition and trial. 

The hygienic management of every case is a matter of importance. 
The general condition of the nervous system should be considered and 
may call for changes in the habits of working, eating, resting, and 
exercising. Tobacco in every form should be denied to subjects of the 
disease. Iron, quinine, nux vomica, cod-liver oil, phosphorus and the 
hypophosphites, arsenic, and strychnine are often indicated, and used 
with great benefit. Crocker advocates the administration of the 
nitrate of pilocarpine Vs to X A grain (0.008-0.01) at night, a flannel 
night-dress being worn subsequently. Pilocarpine by hypodermatic 
injections into the scalp in doses of from %o to /4o grain (0.0015- 
0.006) is also praised. 

There are few patients who are not benefited by daily salt-and- 
water bathing of the entire body-surface, followed by brisk friction, 
especially over the spinal region. In the case of children this treat- 
ment must be conducted by a skilled hand. When practicable the 
cold douche is to be preferred. 

In all cases in which the scalp is involved in either sex, and in 
which the special hypochondriasis of the disease is developed, a wig 
should be worn for the sake of its moral effect upon the sufferer. Its 
use, however, should be limited to social occasions, visits, etc., as the 
persistent wearing of a peruke indoors seems to lengthen the course 
of the disease. 

The indications for local treatment are, by the precautionary 
measures, useful in restricting the spread of ringworm and favus of 
the scalp to prevent possible transmission of the disease to unaffected 
persons, to destroy any parasites that may be present, and to increase 
the physiological afflux of blood to the hair-follicles. With this end in 
view the affected parts are to be bathed daily in water as hot as can be 
tolerated, then dried, and rubbed with a stimulating lotion. After 
the lotion dries it is well to apply an oil or simple ointment. The 
articles usually employed are alcohol, ether, resorcin, formalin, tur- 
pentine, ammonia, camphor, cantharides, carbolic acid, oil of mace, 
croton-oil, tincture of nux vomica, tincture of capsicum, tincture of 
aconite, castor-oil, tar, iodine, sulphur, and the mercurials. All fre- 
quently fail. Several of these substances in combination seem at 
times to be of service. 



974 DISOEDEBS OF THE APPENDAGES. 

The following is a formula, the ingredients of which may be 
varied to suit the indications in different cases. 

# 01. ricini, f^ss; 151 

Acid, carbolic. 3j ; 4 

Cantharid. tinct., 3SS; 15 

01. rosmarin., gtt. xv; 1 

Spts. vin. rectif., ad f^iv; ad 120| M. 

Sig. For external use over the scalp with friction. 

The preparations containing sulphur, resorcin, pyrogallol. and 
chrysophanie acid (which have the disadvantage of staining the hair), 
mercuric chloride, etc., given on a preceding page in connection with 
the treatment of Seborrhcea Capitis, are often valuable. 

Formalin in solutions of 0.5 to 2 per cent, is sometimes efficient. 
It should be used with care, however, as it has occasioned severe der- 
matitis, and in several instances has given light hair a green color. 

Jackson recommends liquor ammonia? fortior, applied once or 
twice daily to the bald areas. Speedy return of hair in a patch of 
alopecia areata has followed the application of pure creosote and also 
of trikresol to the denuded surface, resulting in moderate vesication. 
The spirit of turpentine and pure carbolic and acetic acids have 
similarly been employed ; but caustic applications are to be used with 
caution, and over limited areas at a sitting. 

By many experts, having in mind the probability of a parasitic 
origin, epilation is practised to the extent of removing all the loosened 
hairs and a narrow zone of sound hairs about each patch. By others, 
shaving of the patches is substituted for epilation. The remedies 
selected for application are of the order of parasiticides ; for example, 
mercurials, sulphur and its compounds, chrysarobin, pyrogallol. and 
iodine. 

Repeated blisterings of the scalp with cantharidal collodion, 
croton-oil, spirit of green soap, and petroleum have also been em- 
ployed with success. The ointment of chrysarobin has the disad- 
vantage of staining not only the remaining hairs, but often also the 
face in consequence of the frequency of a transmission to that locality 
through the medium of the hands. When patients, however, consent 
to the use of chrysarobin it is worthy of trial, as its application has 
been followed by a vigorous growth of new pilary filaments. Hodara 1 
states that the application of a 30 per cent, preparation of chrysa- 
robin for from two to eight weeks is followed by vascular and inflam- 
matory changes which lead, through proliferation of prickle-cells 
and connective-tissue cells, to the formation of new follicles, new 
sebaceous glands, new papilla?, and new hairs. Andre employed ten 
hypodermatic injections of pilocarpine muriate in Vs grain (0.008) 
doses, which resulted, in the case of a middle-aged woman affected 
with total symmetrical baldness, in an abundant growth of hair. 
Mercuric chloride has similarly been employed. 

1 Jour. Mai. cutan., 1903, xv., p. 644. 



ALOPECIA ABE AT A. 975 

Phototherapy has been used by Finsen, Forchammer, Jersild, 
Leredde, Torok, Schmidt, and others, including ourselves, in alopecia 
areata with, on the whole, very favorable results. 1 For circum- 
scribed areas the light-treatment gives better results apparently than 
are obtained by other methods, though it fails in some instances. It 
has been used successfully where a number of large areas were pres- 
ent, but in such cases the treatment is tedious, and, as a rule, does 
not give such good results. 

Faradization of the scalp with a stiff wire-brush, pushed to the 
point of producing moderate hypersemia, has been followed by excel- 
lent results. Holzknecht 2 has employed the x-rays in one case with 
a favorable result. 

Wilson recommends : 

I£ 01. amygd. dulc, f 3.1 ; 4| 

Capsici tinct., f 3ij ; 8| 

Liq. ammon. fort., f 5,i ; 30 j 

Spts. rosmarin., f^v; 150| 

01. limon., f 5 j ; 4| M. 

Another stimulating application is : 



01. terebinth.,"! -- »„ 

01. ricini. f aa I 3 S 



151 



Origani tinct., f 5.1 ; 4| 

01. camphorat., f 51 ; 30 

Liniment, volatil., ad f^iij ; ad 90| M. 

Sig. For external use with a brush until the scalp is irritated. 

Shaving should regularly be practiced when in men the region of 
the beard is involved, as the deformity is thus rendered less con- 
spicuous ; and the bald surface should be stimulated frequently with 
one or several of the topical applications named above. Alcoholic 
solutions of resorcin (3 to 20 per cent.) or of mercuric chloride, V2 to 
1 grain (0.033-0.066) to the ounce (30.), are to be well rubbed over 
the patch or patches once or twice daily. 

Prognosis. — From what precedes, it will be inferred that, as re- 
gards the relief of the baldness, the asymmetrical development of 
alopecia areata in youth is much more favorable than the symmetrical 
general disease of middle life, the latter being often remediless. In 
all cases the practitioner should actively persevere to the end. In no 
case should any encouragement be given as to complete relief within 
the year, though exceptionally short careers of the disease are observed 
at times. The prognosis of the same affection of the beard is quite 
favorable, the disease, in young men, usually concluding its stadium 
in the course of about one year, with a favorable termination. 

1 For bibliography, see paper by Frank Hugh Montgomery, J. C. D., 1903, xxi., 
p. 529. 

2 Wien. klin. Eundschau, 1901 (abstr. in B. J. D., 1902, xiv., p. 35). 



976 DISORDERS OF THE APPENDAGES. 

SYCOSIS. 

(Gr., ovkov, a fig.) 

The title " sycosis " no longer indicates an idiopathic affection. 
It is employed in these pages to designate a group of different disor- 
ders, which, affecting for the most part the region of the male beard, 
may be for practical purposes classified as follows: 

Coccogenous Sycosis includes the most numerous of the cases to 
which the term " sycosis non-parasitica " was once given, and which 
are all due to invasion of the pilo-sebaceous crypts by pus-cocci. 
These pyogenic organisms may be either primarily or secondarily ef- 
fective in producing the symptoms of the disease. In many cases a 
suppurative folliculitis follows the disorders included in the group 
last named. A bacillogenous sycosis is described by Tommasoli. 1 

Hyphogenous Sycosis (Barbers' Itch, Ringworm of the Beard) 
is due to the presence of the trichophytons (Trichophytosis Barbce). 
It is described in this work among the Tinese. 

Lupoid Sycosis, Ulerythema Sycosiforme, etc. A group of scar- 
leaving sycosiform dermatoses may also be recognized which differ 
somewhat from those named above. They include the pseudo-sycoses, 
the eczemas limited to the region of the beard with acneiform fea- 
tures, the eczemas of the same region with seborrhoi'c complications, 
certain forms of lupus erythematosus of the beard, and the still rarer 
sycoses possibly due to tuberculous infection of pustular lesions of the 
bearded face. 

COCCOGENOUS SYCOSIS. 

(" JSTon-parasitic " Sycosis, Sycosis Vulgaris, Sycosis Staphy- 

LOGENES, MeNTAGRA, FlCOSIS, FOLLICULITIS BARB2E. Ger., 

Bartfinne, Bartflechte; Fr. Sycose.) 

Symptoms. — The lesions appear upon the face, involving one or 
both cheeks successively or simultaneously, the chin, the upper lip, the 
eyebrows, the scalp, the axilla?, and the pubes. The disease, however, 
is almost always limited to the region of the beard in men. In this 
respect sycosis differs from acne and other disorders of the sebaceous 
glands of the face with which authors have sought to identify it, since 
not only is it, as a rule, strictly limited to the region of the beard, but 
also the non-hairy portions of the face of the patient are free from 
comedones, acne-lesions, and other symptoms of a cutaneous disorder. 

When seated upon the upper lip the first symptoms may be those 
of a nasal catarrh ; seated elsewhere an eczematous attack may precede 
the onset of the disease. It may be ushered in with the acute symptoms 
exhibited in the early stage of some forms of eczema, and with tume- 
faction accompanied by a sensation of heat and burning; but often a 
few isolated and indolent lesions, the presence of which scarcely awak- 
ens attention, are the first traces of the disorder. Soon there may be 

1 Monatsh., 1883, vii., p. 403. 



COCCOGENOUS SYCOSIS. 



977 



recognized a larger or smaller number of discrete, pin-point to split- 
pea-sized, flattened or conical, reddish and painful papules, tubercles, 
or pustules, the anatomical seat of which is distinguished as the pilary 
follicle because of the penetration of each lesion by a filament of hair. 
These lesions may persist, and when typically discrete and visible at 
the part at which the hair makes its exit from the duct of the follicle 
they suggest the appearance of the surface of the fig, whence the dis- 
ease derives its name. They are apt to occasion a burning and at 
times a decidedly pruritic sensation when, being picked or torn open 
by the fingers, the pus concretes into a crust at the base of the hair. 
In severer cases these lesions, while not coalescing, are so closely set 
together as to form a patch of continuous infiltration. These patches 
may be weeping or be crusted ; in the latter case the crusts are apt to 
be small and numerous, each crust being limited to the shaft of a 
single hair, and leaving when removed a minute crateriform excava- 
tion at the mouth of the follicle. 

Involution of several lesions may be followed by fresh crops, and, 
sooner or later, distinct patches of disease are thus formed. When 



Fig. 


200. 




1 




m 


| 




pF-> ; 


, ■ 






/^M 


( 





Sycosis vulgaris. 



fully developed the surface of the skin is reddened, swollen, infil- 
trated, and thickened; covered irregularly with papules, pustules, 
crusts, and scales, and frequently with excoriations. The disease 
often lapses into chronic conditions, usually the result of improper 
treatment, and in ancient cases the deformity is characteristic and 
62 



978 DISOEDEES OF THE APPENDAGES. 

totally unlike that produced by the vegetable parasites. The hairs 
are usually fixed firmly in their follicles, but from those in which ac- 
tive suppuration is in progress the hairs may be plucked without 
occasioning much pain. In cases which have been treated for years 
the hairs are thinned and decidedly lack vigor. 

In typical and neglected cases of long standing, in which the 
region of the beard is involved, an important clinical feature is the 
symmetrical, general, and uniform involvement of the entire surface. 
The picture of one cheek is very nearly that of the other. The sparse 
hairs scarcely serve to disguise the reddened, tumid, painful surface 
beneath, which displays the severe lesions of the malady. Furuncles, 
abscesses, cicatrices, vegetations, and eczema of the ears may compli- 
cate the process. Sycosis is occasionally acute in its course, but is 
more often chronic and rebellious. A typically chronic and untreated 
case of the malady rarely terminates by spontaneous involution. 

The thinning of the hairs, described above as a consequence of 
long persistence of the disease, is far more characteristic than any 
distinctly resulting alopecia ; the latter, however, very rarely occurs, 
but is then remediless. The same may be said of resulting cicatriza- 
tion, which is one of the rarest consequences, and which is generally 
due to bacillogenous infection. 

The absence of certain symptoms in this disorder is as significant 
as is the presence of others. Adenopathy of the cervical glands is 
very rare., but when present it should awaken suspicion of another 
malady. The disease when of longest persistence as to time produces 
great unsightliness, but not the deep-seated, subcutaneous, small- or 
large-nut-sized nodules or tubercles, forming the " lumps " so charac- 
teristic of trichophytosis of the beard. Sycosis vulgaris is a disease 
of chronic course, which may endure for years and be characterized 
by relapses and aggravations, but is entirely curable ; it is only in ne- 
glected and improperly treated cases that such persistence may be 
expected. 

Scar-leaving Sycosiform Dermatosis (Lupoid Sycosis, Ulerythema 
Sycosiforme, Seborrhee depilante). — Under these titles has been de- 
scribed a somewhat rare aifection of the skin of the bearded face in 
men, the symptoms of which at the outset are practically those of 
sycosis vulgaris. In the course of the disease, however, whether in 
consequence of an added infection or as the result of the evolution 
of the malady, a change occurs in which the hair-follicles atrophy and 
considerable scarring results. The scars are often irregularly de- 
pressed between ridges and linear elevations of the surface. By 
TJnna this dermatosis is grouped with a class of disorders to which he 
has given the title of " ulerythemata." The disease is at times a 
tuberculous complication of ordinary sycosis or one dependent upon 
the presence of tubercle-bacilli, as we have had occasion to demonstrate. 
The course of the aifection is exceedingly chronic, lasting, with alter- 
nations of improvement and aggravation, for several years. Accord- 
ing to Robinson, the inflammation in these cases spreads peripherally 



COCCOGENOUS SYCOSIS. 



979 



upward or downward with a narrow infiltrated margin. The lesions 
outside of the follicles may be papular, vesicular, or pustular in type. 
The tendency to extension from a given centre and to irregular scar- 
ring are the chief characteristic features of the malady. 

Many of these cases strongly suggest in their features the symp- 
toms of lupus erythematosus. In some instances the two affections 

Fig. 201. 




Lupoid sycosis. 

are indistinguishable. The malady is exceedingly obstinate and 
often requires severe local treatment. 

Etiology. — Sycosis vulgaris is unquestionably due to either pri- 
mary or secondary invasion of the pilo-sebaceous follicle by microor- 
ganisms. Obviously in many cases there is a special reason for the 
accessibility of the germs to the crypts where they are lodged. Shav- 
ing, and the use in common of towels, brushes, •combs, etc., in public 
establishments (club-houses, barber-shops, hotels), and the employ- 



980 DISOEDEES OF THE APPENDAGES. 

merit of pillows, lounges, and reclining-chairs in public resorts are 
often the origin of the mischief. 

The disorder is encountered chiefly among men after puberty, and 
in those of all social conditions and grades of health. It is not trans- 
missible by heredity. The mere performance of shaving is not known 
to produce it. At times the immediate cause of the disease is recog- 
nized when the upper lip is constantly irritated by a discharge due to 
profuse nasal catarrh. In other cases, again, all the causes of eczema 
may be invoked in explanation of the result. 

A careful study of many cases suggests that the hairs themselves 
are among the aggravating causes of the disease and the sources of its 
peculiar obstinacy. In health the motions of the free shaft of the 
hair do not irritate the follicle in which it is set ; in conditions of dis- 
ease it is quite different. Each free hair operates like a lever upon 
the inflamed ring-tissue which encircles it on its escape from the follicle 
beneath, and thus by the touch of the hand, by the action of brushing, 
by currents of air, or by any agency whatever, movement may be im- 
parted to it. Every such movement teases to a variable degree the 
previously irritated surface beneath; and when estimate is made of 
the hundreds of such movements to which each hair is subjected dur- 
ing a period of twenty-four hours, the relative importance of this ap- 
parently insignificant factor may be appreciated. 

Pathology. — The disease is due to pyogenic cocci exciting an in- 
flammatory process, which, whether originally follicular or perifollicu- 
lar in seat, may extend either toward or from the follicle. Sometimes 
extraction of the bair is followed by a drop of pure pus which exudes 
from the follicle, and the root-sheaths of the hairs are seen to be 
altered in consequence of the circumscribed follicular abscess. At 
other times the follicle itself is free from disease, and the exudative 
process has evidently expended itself upon the perifollicular or even 
the interfollicular tissues, in which case the papillary layer of the 
derma exhibits the usual phenomena of hyperemia, infiltration, and 
multiplication of protoplasm, with abundant vascular dilatation. 

According to Robinson, the disease always begins as a perifollicu- 
lar inflammation, under the influence of which transuded serum pene; 
trates the follicle. Maceration and eventual destruction of the root- 
sheath of the hair result with the ultimate production of pus within 
and without the follicle. The pus, when the hair remains in the fol- 
licle, finds its way to the surface by breaking through the epidermis 
near the hair; occasionally exit is obtained between the shaft and 
the follicle-sheath. 

The hair-papilla usually escapes destruction, so that permanent 
alopecia seldom follows. The sebaceous glands are occasionally in- 
volved and even destroyed, but the coil-glands are affected in excep- 
tional cases only. The hair, according to Unna, is closely encapsuled 
by horny cells which surround the neck of the hair-follicle, like a 
horse-collar. "When pus is formed in the cutis, colonies of cocci spread 
from about the neck of the follicle into the cutaneous abscess and 



COCCOGENOUS SYCOSIS. 981 

sometimes as deeply as the hypoderm. The cocci may also accumu- 
late within the follicle. In total suppuration of the follicle the 
tightly packed cocci fill the hair-fissure, occupy the centre of the 
follicular abscess, and extend parallel to the skin on the under margin 
of the abscess. 

The microorganisms recognized (by culture and reinfection) as 
the effective agents in the production of Tommasoli's bacillogenous 
sycosis were bacilli with rounded extremities presenting an elliptical 
or ovoid appearance. They measured 1.0 to 1.5 by 0.25 to 0.3 /a. 
The symptoms clinically resembled those of coccogenous sycosis. 

Diagnosis. — The most important consideration here is the dis- 
tinction between the coccogenous and the hyphogenous diseases of the 
region of the beard, upon which point, naturally, the microscope fin- 
ally decides. Still the clinical features of the two affections are quite 
distinct. The coccogenous form is recognized: (a) by the greater 
redness of the involved surface; (Z>) by the extension of the disease 
in advanced cases to larger areas of symmetrical involvement; (c) 
by the more superficial character of the lesions ; and (d) by the firm 
implantation of the hairs in their follicles in the earlier periods of the 
disease, their relative freedom in all cases from fracture, and the ab- 
sence of stumps. The hyphogenous disease of the hairs is peculiar, 
in consequence of : (a) decidedly less redness of the surface attacked ; 
(6) the frequent limitation of the malady to a circumscribed area, or 
to several such, irregularly dispersed over a large region; (c) the pe- 
culiar " lumpy, tubercular, nodular, and uneven " characters of the 
patch, upon which Duhring has laid significant emphasis ; and (d) 
the earlier loosening of the hairs in their follicles, as also of the oc- 
currence of fractured hairs and of stumps, exhibiting usually at the 
bulb unmistakable evidences of the nature of the disease. The ma- 
lady is often mistaken for syphilis, chiefly on account of the unsight- 
liness it produces; but the pustular syphiloderm is very much less 
chronic in its course, is rarely limited for years to the face exclu- 
sively, and, when long persistent in one locality, is characterized by 
ulceration and the production of very characteristic crusts. 

Eczema may complicate the coccogenous disease by preceding or 
by following it, but typical instances of the two disorders may be 
recognized by the occurrence, in the case of eczema, of a discharging 
disease, not usually limited to the region of the beard, characterized 
by a more intense itching, and with marked absence of the papulo- 
tubercular lesions described above. The lesions in eczema, moreover, 
are not invariably perforated by hairs. The shaven face affected 
with erythematous eczema is reddish in color, and desquamates, after 
full evolution of the disorder, without pustulation. 

Treatment. — Fox 1 Gildersleeve 2 and Schamberg 3 have reported 
such good results from the use of staphylococcus vaccines that their 
employment is at least worthy of careful consideration. Kadiother- 

1 B. J. D., 1907, xix., p. 420. 

2 J. C. D., 1907, xxv., p. 320. 

3 Sixth, Internat. Derm. Cong., p. 290. 



982 DISOBDEES OF THE APPENDAGES. 

apy is also a very effective method of treatment. The technique is that 
recommended for acne, except that a harder tube is employed. The 
treatment is carried to the point of producing a slight erythema and 
fall of the hair. In the majority of cases from four to eight exposures 
suffice and the reaction subsides within six weeks. The hair returns 
usually in about two months. In one case of lupoid sycosis of seven 
years' duration the active lesions disappeared and the scars became 
much less conspicuous. In several other instances of this disorder 
this method of treatment has been of special value. 

In all cases of sycosis, except those treated by re-rays, the essential 
and important step is the continued removal of the hairs which, as 
indicated above, are the chief sources of aggravation of the disease. 
This removal is accomplished best by epilation or by shaving, which, 
though often painful at the onset, soon is tolerated well by the suf- 
ferer. The majority of patients, however, object to the removal of 
the beard, far more on account of the consequent greater exposure to 
view of the unsightliness induced by the disease (then no longer 
partly masked by the hairs) than on account of the distress occa- 
sioned by the operation. To these objections there is but one re- 
sponse — the shaving is essential ; the deformity is relieved rapidly 
after its successful initiation ; the discomfort diminishes with each 
repetition of the process. For the disease in patients positively re- 
fusing to have the beard removed, whose cases are so severe as to 
require it, the practitioner will do well to decline to be responsible. 
There is no limit to the tedious and obstinate course of the malady in 
the one case, and in the other the results are speedily satisfactory, 
often in the course of a few weeks. 

When there is much tenderness, pain, swelling, pustulation, or 
crusting, the hairs may first be clipped short, and a bland poultice of 
oil, elm-bark, or of bread and milk applied. The practice in Vienna 
is to substitute for the poultice, strips of soft muslin or linen spread 
with diachylon ointment, firmly bandaged over the cheeks, chin, or 
lips for from twelve to twenty-four hours, after which a razor is 
passed over the entire surface. The integument which thus becomes 
visible is usually a reddened infiltrated area, with pustules, papules, 
pustulo-papules, and some crusts dispersed here and there over it. 
After exit is given to all purulent collections this area is best treated 
by hot-water lotions, borated or alkalinized, and then a bland oint- 
ment is to be applied at night and a borated dusting-powder in the 
morning. Formalin lotions of the strength of 1 to 2 per cent, are 
valuable in all stages of the disorder. The subsequent treatment is 
largely that of eczema of equal grade of severity. In the more acute 
periods oleated lime-water, medicated with calomel or with zinc oxide, 
f to 1 drachm (2.-4.) of either to the pint (500.), may often be 
employed with benefit ; or for this application may be substituted 2 
ounces (60.) each of linseed-oil, Castile soap, and paraffin, to the pint 
(500.) of liquor calcis. Later, the Lassar paste or ointments may be 
used, particularly cold-cream salve, to which may be added either 



COCCOGENOUS SYCOSIS. 983 

sulphur, zinc oxide, or, less preferably, one of the mercurials. Lo- 
tions of mercuric chloride, sulphur, alcohol, cologne-water, or iodated 
glycerin may be useful in stimulating indolent patches of infiltration. 
The treatment of these patches is indeed that of chronic eczema. 

Epilation is often essential for relief of the disease ; and in chronic 
cases severe methods have been employed, including the use of green 
soap, tar, and cauterization with acetic and even with nitric acid. 
Erasion with the curette is to be named in the same category. These 
measures have been employed in aggravated cases ; but as the disease 
is certainly curable in a majority of patients without having recourse 
to these heroic methods, they are to be regarded in the light of a 
dernier ressort. It is not necessary in the majority of coccogenous 
forms of sycosis either to epilate or to employ caustics. By repeated 
and frequent use of hot borated water, formalin lotions, and the 
milder stimulants, with constant shaving, the desired result is usually 
within reach. Shaving should be continued for nearly a year after 
all traces of the disease have disappeared ; and it is a point of some 
importance to substitute for a fatty application a continuously ap- 
plied borated powder as soon as the skin will tolerate the persistent 
use of the latter. 

Van Harlingen advises for acute cases a wash composed of -| 
pint (250.) of rose-water, to which 1 drachm (4.) each of precipi- 
tated zinc carbonate and zinc oxide in powder have been added, with 
2 drachms (8.) of glycerin and dilute liquor plumbi subacetatis. 
Veiel recommends a solution of pyrogallol (1 part to 50) for painting- 
over the region affected, followed in the day by emollient cataplasms 
and in the night by diachylon or weak tannin ointments. Sycosis of 
other portions of the body is to be treated as described for the region 
of the beard. 

Internally, treatment, when indicated, should be of the kind de- 
manded by the condition of the patient. It is a matter worthy of 
special attention, however to purge every previously treated case, of 
suspicion of artificial element, by withdrawing for a time all internal 
medication. The disease is so disfiguring that many patients swallow 
potassium iodide, arsenic, and other deleterious drugs for months 
before consulting one who is wiser than they in these matters. Ex- 
posure of the face to dust, smoke, wind, and other sources of irritation 
should for a time be avoided. 

In the hygienic management of these cases all use of tobacco and 
alcoholic beverages is to be abandoned. Even the drinking of hot 
tea, coffee, and stimulating beverages of other kinds is to be inter- 
dicted. The diet should be of the simple character recommended in 
eczema. Inasmuch as many patients suffer from a coincident nasal 
catarrh, hot baths should be exchanged for daily cold sponging of the 
body-surface, for patients able to endure the shock, followed by brisk 
friction with flesh-brush or with coarse towels. 

In acute cases it may be desirable to begin treatment with a brisk 
mercurial cathartic ; the alkaline diuretics advised by authors will, at 



984 DISORDERS OF THE APPENDAGES. 

least, do no harm if judiciously employed. The same may be said 
of calx sulphurata and minute doses of calomel in the pustular stages 
of the affection. But in other cases cod-liver oil and iron are de- 
manded by the general condition of the patient, usually one of the 
class exhibiting the evidences of " hospitalism." Xo firm believer in 
the coccogenous etiology of the disorder will, however, expect by these 
measures alone to relieve the disease. 

Prognosis. — The disease is entirely curable, and will, in the large 
majority of all cases, either disappear entirely or greatly be improved 
by judicious treatment. The latter requires the personal supervision 
of the physician and close attention to details. 

In exceptional cases the disorder is exceedingly chronic and ob- 
stinate, and requires perseverance on the part of both physician and 
patient to attain the desired end. Relapses are of frequent occur- 
rence, due usually to neglect of asepsis after apparent recovery. In 
a few very rare cases (lupoid sycosis, tuberculosis) there is cicatricial 
tissue left after repair. 

FOLLICULITIS ATROPHICANS.! 

This term is employed to designate a class of disorders character- 
ized by disease of the hair-follicles terminating in their atrophy. We 
are especially indebted to Brocq for what little is known regarding 
these rare affections. The group includes: 

Ulerythema Ophryogenes (Gt. 6v\rj, scar; ipv6rjfia } redness; o(f>pvs, 
brow). — This affection was described first by Taenzer 2 in Unna's 
clinic. According to Unna, it occurs most frequently in blonde in- 
fants, is located usually in the eyebrows, from which it may spread to 
adjacent parts, including the scalp, or it may appear on the extensor 
surfaces of the upper arms. The condition may be no more than a 
persistent erythema, with small, elevated, horny papules at the 
mouths of the hair-follicles. The hairs are finer than normal and usu- 
ally are broken off close to the surface. The disease may persist for 
years without further change, but in the severer forms superficial in- 
flammation, atrophy, both follicular and interfollicular, results, so 
that small depressed scars are surrounded by, or commingled with, 
the hypersemic areas. The resulting alopecia is permanent and may 
be very marked, especially on the eyebrows. 

The disease is said to be rebellious to treatment. Internally a fer- 
ruginous and arsenical treatment has been adopted with local applica- 
tions of resorcin, salicylic acid, the mercurials, and stimulating 
shampooings with soap. 

Quinquaud's Disease 3 (Acne Decalvante of Pailler and Robert). 
Here miliary abscesses, punctiform, pinhead-sized and larger, involve 
the follicle. The hair originally piercing these suppurative lesions is 

1 Cf. La Pratique Dermatologique, vol. i., p. 335. 

2 Monatshefte, 1888, No. 5. 

3 Bull, cle la Soc. med. des Hop., 1888, s. iii., v., p. 395. 



FOLLICULITIS ATROPHICANS. 985 

loosened and falls, after which the follicle atrophies and the hair is no 
longer produced. The scalp is left dead-white, thinned, depressed, 
atrophied, and cicatriform, in patches as large as those visible in alo- 
pecia areata, but often irregular in outline. The follicles remain 
distinct and are not fused into a mass ; they resemble the distribution 
of the lesions in coccogenous sycosis. In some instances this special 
follicular alopecia and scarring have progressed without suppurative 
involvement of the follicle, and in cases without any signs of in- 
flammation. 

Alopecie Cicatricielle Innominee (Pseudo-pelade) consists of a slight 
inflammation of the scalp in patches leaving permanent alopecia. In 
these cases the scalp about one or several hair-follicles becomes tumid 
and reddened. The hair is loosened in its pouch, and, whether it fall 
spontaneously or be removed by epilation, it is not replaced by an- 
other. The scalp is left whitish, smooth, ivory-like, depressed, 
thinned, insensitive, and apparently atrophied, without trace of the 
new-formed downy hairs often noticed in alopecia areata. As distin- 
guished from the last-named disorder, the advance of the patch may 
be in irregular lines rather than by extension of the rounded or oval 
circles formed in alopecia areata. Minute islets of bald areas exhibit 
the outlying evidences of disease. 

Etiology and Pathology. — There can be no question that some 
of the cases designated in the group of affections outlined above are 
instances of lupus erythematosus of the scalp. Some of them exhibit 
the border, the color, the thickening, and the characteristic stippling 
of patches of that disease. Until lupus erythematosus of the scalp 
has been studied exhaustively, its existence in this region, when there 
are no facial or other lesions to indicate its character, will scarcely 
fail to be misunderstood. 

Diagnosis. — The diseases which must be excluded carefully in the 
presence of a given case are : lupus erythematosus, lichen planus lim- 
ited to the scalp which is very rare, scleroderma and post-impetigin- 
ous scars of the scalp. A careful consideration of the symptoms of 
these diseases is required in every case. 

Treatment. — The internal and local treatment is practically that 
of alopecia already detailed. Clipping, epilation, the application of 
parasiticides, and the remedies advocated in alopecia seborrhoica are 
often useful. Sulphur, resorcin, the mercurials, salicylic acid, and 
iodine all have been employed with success. Corrosive sublimate 
lotions, 1 in 400, boric acid lotions, and powders are useful. Gal- 
vano-cauterization of the pustules and inflammatory points has been 
employed successfully in some of the reported cases. All these dis- 
orders are well managed if treated in accordance with the principles 
suggested in the section on Sycosis. 

Prognosis. — The disease is often severe, obstinate, deforming, and 
rebellious to treatment. The prognosis of the lupoid sycosis type 
promises to be improved greatly by the employment of radiotherapy. 
The resulting alopecia in most forms is remediless. 



986 DISORDERS OF THE APPENDAGES. 



KELOID-ACNE.i 

(Sycosis JSTuchje Necrotisans, Dermatitis Papillaris Capil- 
litii. Fr., Acne keloidienne; Ger., JSTackenkeloid. ) 

Under this title Kaposi 2 describes a disorder characterized by 
pinhead-sized, isolated or confluent elevations of the skin-surface, 
with interspersed pustules, which finally form cicatriform plaques 
over which the hairs are either clustered in tufts or are totally absent. 
The pilary filaments are atrophied yet firmly fixed in their follicles, 
and they suffer elongation or fracture before withdrawal. The dis- 
ease is encountered chiefly upon the nucha, the occiput, and the ver- 
tex. Papillomatous vegetations, crust-covered, hemorrhagic, and with 
a foul-smelling secretion, sometimes form, and eventually retract into 
a sclerotic tissue. 

I have described typical cases of this disorder, 3 each of 
which concluded with the production of a keloid-like, cicatriform. 
irregularly shaped but circumscribed elevation of the surface. This 
feature is that by which it specially differs from all other sycosiform 
disorders. The disease seems to be due fully as much to inflamma- 
tory processes in the subcutaneous tissue between the unyielding peri- 
cranium and the thick scalp as in the derma proper, and therefore it 
is not, strictly speaking, a dermatitis. Puncture, for example, of one 
of the pinhead-sized pustules commonly gives exit to the usual quan- 
tity of pus; but pressure upon the scalp in the periphery will at once 
be followed by the appearance of a still larger quantity of similar pus 
which evidently is expressed from a circumscribed subcutaneous ab- 
scess. When by such pressure the abscess-cavity is emptied it slowly 
fills with venous blood and* produces a firm, semisolid elevation of 
the surface that subsequently undergoes sclerosis, and the starved 
hairs above behave in the manner described by Kaposi. The papules 
and plaques are formed in a similar way by the abundant supply of 
venous blood. The case of one of the patients presented at the clinic 
had been erroneously diagnosticated by a surgeon as aneurismal in 
character. Puncture of all such semisolid, cicatriform lesions is 
invariably followed by oozing of venous blood in abundance. The 
disease is chronic in character, is particularly liable to relapse in 
crops of pilary or peripilary pustules and papules, and it extends 
from nucha to vertex, avoiding the frontal and temporal regions. 
Over the bald or partially bald keloid-like elevations there is seen, 
in some cases, a species of seborrhcea in the form of more or less 
adherent, fatty crusts, with occasional characteristic tufts of hairs. 

The disease seems to owe its special character to the anatomical 
peculiarities of its location. It occurs preferably at the points where 
the venous supply of the scalp is not only greatest, but where it is 

1 For a survey of the literature, with clinical and histopathological report, see 
Porges, Archiv, 1900, lii., p. 323. 

2 Treatise, Wien, 1880. 

3 J. C. D., 1882, i., p. 33. 



EELOID-ACNE. 987 

also in most direct connection with the large vessels beneath, and 
where an inflammatory process in the derma or subcutaneous tissues 
invites with readiness a pathological afflux of blood. Such a focus, 
limited beneath by the dense calvarium, and above by the relatively 
thick scalp, readily undergoes organization and sclerosis, the subse- 
quent behavior of the hairs and fair-follicle being an accident of 
the process. 

According to Besnier and Doyon, the disorder is a papillomatous 
development, likely to occur in this region of the scalp as a sequel of 
epilation, cicatricial (keloid) acne, eczema, or traumatism. 

Sangster (in a paper read before the International Medical Con- 
gress in London, 1881) described a pigeon' s-egg-sized tumor of the 
scalp, that Kaposi, who was present, recognized as a case of derma- 
titis papillaris capillitii. Crocker describes in detail a similar case, 
an occipital lesion measuring three and one-half by two and one-half 
inches. 

Ehrmann 1 believes that this affection is simply the terminal stage 
of coccogenous sycosis. Samberger 2 has described the malady affect- 
ing the follicles of the beard. 

The therapy of this rare disease can scarcely be described as estab- 
lished. Internal treatment is suggested by the constitutional condi- 
tion of the patient, and it should often include cod-liver oil, the fer- 
ruginous tonics, and a roborant regimen. The affected surfaces are 
freed first from subcutaneous abscesses by puncture and expression of 
the contents. Then the patch is washed with hot carbolized water, 
dusted with boric acid or iodoform, and a compress, moistened with 
an antiseptic solution, such as corrosive sublimate wash, is bandaged 
firmly over the part. When pathological fluids no longer form under 
the scalp the patch is best epilated and anointed with a salve contain- 
ing 1 drachm (4.) of precipitated sulphur to the ounce (30.) of 
scented vaselin, which salve may also be kept constantly over the part. 
When crusts form they may be removed by shampooing with green 
soap. Other methods of local treatment advised are: electrolysis, 
linear scarification, erasion, excision, and electro-cauterization. 

The favorable results obtained with the x-ysljs in acne and in 
keloid suggest the use of radiotherapy in keloid-acne. We have used 
the method in two cases, succeeding in both instances in arresting the 
active process and in causing a partial disappearance of the disfigur- 
ing scars. 

DECIDUOUS HAIR SHEDDING. 

Ledermann 3 has reported the case of a girl twenty-two years old, 
who shed her hair every winter; in summer it would grow again. 
One winter she became entirely bald and in summer her hair did 
not grow as usual. Severe alopecia affected the body. This began as 
circular patches when she was twelve years old. 

1 ArcHv, 1895, xxxii., p. 324. 
2 Archiv, 1907, lxxxiii., p. 163. 
3 Berl. klin. Woch., 1903, p. 332. 



988 DISOBDEBS OF THE APPENDAGES. 



THE NAILS. 1 

The importance of a careful study of the diseases of the nails can 
scarcely be overestimated. These appendages to the distal phalanges 
of the hands and feet are involved, slightly or seriously, in most of 
the morbid changes in the general economy; and exhibit also path- 
ological features limited to the nail-organs themselves. Singularly 
sensitive, they give response to almost every one of the traumatisms, 
the invasions, and the reactions of the human body. 

Surveying the diseases of the nails as a group, certain general 
considerations are noteworthy, apart from a formal enumeration of 
the etiological factors efficient in different cases, as explaining alike 
the vulnerability of the nails and the special opportunities for their 
involvement. 

Of all organs of the body, the nails are furthest distant from the 
circulatory centre and thus, in a remarkable degree, acknowledge the 
influence of both slight and serious embarrassments of the vascular 
currents. At the same time, as a consequence of the isolation of the 
digits on which they are implanted, they share with the ears the 
dangers of exposure to low temperatures. These striking facts alone 
explain a large number of the diseases not due, as in the case of 
parasitic invasion, to a morbid process limited to the nail-organ. 

In most individuals of civilized races, the act of locomotion brings 
special stress to bear upon the toes through the medium of the arti- 
ficial coverings worn upon the feet. In persons wearing no protec- 
tion of that character, the toe-nails share with the finger-nails, but 
only in minor measure, the chances not merely of direct infection, 
but also of furnishing, for a variable period of time, lodgment for 
microorganisms beneath the free border of the nails and in the nail- 
folds. In the vast majority of members of the human family, the 
infant, the child, and the man during all the wakeful hours of the 
day, bring the finger-nails into intermittent contact, both with other 
exterior regions of the body and with the objects in its immediate 
environment. The nails, therefore, not only suffer from many dis- 
eases affecting the general economy as well as from morbid condi- 
tions limited to the nail-organs themselves, but also are often the 
agents by which infective processes are awakened in distant but acces- 
sible regions. 

1 Keeent literature on Diseases of the Nails in general : Heller, Die Krankh. d. 
Nagel, Berlin, 1900, with 71 illustrations and bibliography to date of publica- 
tion. Heller, Mracek's Handbuch, 1907, vol. iv., ii., p. 538, with additional 
bibliography to date of publication. Shoemaker, J. C. D., 1890, viii., pp. 334, 
388, 419, 476, with references and abstracts. Montgomery, D. W., Twentieth 
Century Pract., vol. v. ; Trans. Amer. Derm. Assn. (symposium on Dis. of Nails, 
Grindon, Pollitzer, Zeisler, Hardaway), 1901, p. 111. Eadcliffe-Crocker, Dis. of 
the Skin, 3d and Spec. Hid. Ed., 1905, p. 1248, with good portrait of onychogry- 
phosis, Atlas, pi. xc. Pernet, Encyclop. Med., vol. viii., 1901, with bibliography; 
Atlas of 111. of Med., Surgery and Path., London, New Syd. Society. 1906. 
Hutchinson's Arch, of Surgery, 1890-1891, vol. xl, p. 237-253. Dubreuilh, La 
Prat. Derm. Besnier, Brocq, Jaquet, Paris, 1902, p. 607, art. Ongle, with illus- 
trations. 



ABNORMAL CONDITIONS OF THE NAILS. 989 

CONGENITAL ANOMALIES OF THE NAILS. 

Anonychia (Gr., a, privative; 6W£, nail). — Nail-plates may be 
wholly or partially absent in the new-born, even with normal develop- 
ment of phalanx, nail-bed, and nail-fold. Very rarely all the nails, 
in a few instances one or several of those of the fingers or the toes 
have been wanting. Cases of congenital anonychia are on record in 
which in after life, the nails did not develop. In other instances, 
nails existing at birth have soon afterward been shed without further 
production of nail-growth. Again, the new-born suffering from intra- 
uterine affections of the skin may exhibit a loss of nails due to such 
congenital disease, as in severe grades of ichthyosis ("harlequin 
foetus"), variola in utero, etc. 

Polydactyly and Syndactyly (Gr., 7ro\v<; : numerous; <rvv } together; 
Sd/crvXos, a finger or toe). — Supernumerary fingers and toes com- 
monly have properly adjusted nails ; in some such anomalies, how- 
ever, the nails have been wanting; in yet others double nails have 
existed on the supernumerary digit. In a case of infantile syndac- 
tylism recently submitted to us, two fingers of one hand were en- 
wrapped in a single web; the nails were normal and skiagraphy 
showed proper phalanges. Often, however, the nails of such conjoined 
digits are fused. In yet other cases claw-like nail-plates are developed. 

Onych-heteropia (Gr., ow£, nail ; erepos, different). — In rare cases, 
where rudimentary fingers and toes have been implanted elsewhere 
than upon the hands and feet, nails have been produced in anomalous 
situations. 

ABNORMAL CONDITIONS OF THE NAILS ASSOCIATED 
WITH CONGENITAL CUTANEOUS AFFECTIONS. 

Diseases of the nails in this group, aside from anonychia men- 
tioned above, are occasionally exhibited in new-born infants. The 
most of these cases illustrate the changes described below under the 
titles onychauxis, onychogryphosis, and onychatrophy. At times 
one or more, rarely all, the nails of both hands and feet are defective 
in production of the horny substance of the nail ; or the extremity of 
a bulbous and deformed digit may be capped with greatly enlarged 
nails ; or with nail-plates forming upward-projecting, horny, peg-like 
structures ; or a well-marked sub-ungual keratosis may have been de- 
termined. The congenital affections of the integument most often 
concurrent are : ichthyosis of the so-called " hystrix " type, pityriasis 
rubra pilaris, lepra, and, very rarely, syphilis. With these anomalies 
may exist partial or total absence of hair from the scalp, brows, and 
other regions of the body, as also failure of eruption of the teeth. 

Onychomadesis (Gr., oWf, nail; iiahd(o J to make bald). — Mont- 
gomery 1 reports a case of hereditary continuous shedding of the 
finger-nails in a male patient thirty-five years of age troubled in this 
1 J. C. D., 1897, xv., p. 374. 



990 



DISORDERS OF THE APPENDAGES. 



way from birth. The nails of the mother and two maternal uncles 
had been similarly affected. In this case there had been albuminuria. 
One or two of the nails were constantly falling after a yellowish-white 
change in the lunula. There were no subjective sensations. 

Pachyonychia congenita (Gr., Trax^, dense; ow|, nail). — Under 
this title Jadassohn and Lewandowski 1 describe the case of a girl 
fifteen years of age affected with onychogryphosis of the nails of 
both the fingers and toes, which were somewhat thickly stained though 

Fig. 202. 




Onychogryphosis in a leper, a Hindoo afflicted with the neural form of leprosy. 
(Douglass W. Montgomery.) 



generally transparent, but which were thickened to the extent of from 
three to five millimeters. The density of the structure was such that 
the free extremities of the plates could not be cut with ordinary 
scissors. This condition had existed since birth. There was present 
kyperhidrosis of the hands and feet as well as of the nose, and yellow- 
ish-white transformation of the epidermis of the soles of the feet 
where there had been maceration (c/. the acquired form of compensa- 
tory onychauxis). There was coincident leukokeratosis of the tongue 
and circumscribed follicular disseminate keratosis of the skin. 

Onychogryphosis congenita (Gr., oWf, nail; ypviros, crooked). — 
Sympson 2 describes the case of a child eleven years of age, whose nails, 
both of the fingers and toes, since birth, projected upward from one- 

1 Ikonographia Dermatologica, Fasc. 1, Tab. 1, viii., p. 29. 

2 Lancet, April 14, 1888, p. 722. 



ACQUIRED DISEASES OF THE NAILS. 991 

half to three-fourths of an inch. There was no explanation of the 
anomaly furnished in the history of the patient or her family. A 
similar instance is reported by Zeisler 1 in an infant of three months. 

Fig. 203. 




Onycliogryphosis. (Douglass W. Montgomery:.) 

The two cases presented a striking similarity in that in each instance 
a serum-like oleaginous fluid escaped when the nails were cut. 

ACQUIRED DISEASES OF THE NAILS. 

Onychatrophia (Gr., ovvf; } nail; ar/oo^o?; Fr., Onychatrophie). — 
Atrophy of the nails is always a symptomatic condition, due either 
to a local or systemic influence whereby the formation of the horny 
material of the nail is rendered either wholly abortive or defective. 
In these cases the nail-plates may be changed in bulk, color, elasticity, 
firmness, shape, or position. They may be thinned and expanded, 
narrow and acuminate, friable, furrowed, laminated, ridged, or in 
other ways distorted. They may be striped, irregularly speckled; 
lustreless, or have a characteristic dull yellowish color with " worm- 
eaten " aspect. In other conditions the nails are split, or even crum- 
bling, so that the relics only of the nail-substance are visible near the 
x Loe. cit., p. 128. 



992 DISOKDEES OF THE APPENDAGES. 

matrix, one-half or more of the distal flange having disappeared. In 
yet other cases sparse, horny spurs, " flakes " or pegs, of a dull green- 
ish or dirty hue project from the proximal portions of the nail-bed. 

Hapalonychia (Gr., airaXos, soft; owf, nail). — Under this title 
Kaposi has described a condition of atrophy in which through defec- 
tive nail-production the plates become softened and correspondingly 
weakened, being thus the more readily split and folded. In a striking 
instance of this anomaly shown at our clinic in the person of an 
elderly man in an advanced stage of nephritis, the softened nail- 
plates were thrown into flutings and folds. Under the title Koilony- 
chia ("Spoon-nails," Ger., Aushohlung der Nagel) still another 
atrophic condition has been described by Radcliffe-Crocker, 1 James, 
Rille 2 and others in which the plates, usually of the fingers, are thinned 
and present a transverse concavity with everted edges, the hollowing 
being at times longitudinal. This anomaly has been observed, as in 
other atrophic states of the nail, in connection with wasting diseases, 
but the etiology is often obscure. 

Onycholysis (Gr., 6Wf, nail; A.u<x*9, loosening; Fr., Decollement des 
Ongles). — Partial loosening of the nail from its bed occurs (a) when 
the plates are only partly dislocated, a condition affecting chiefly the 
proximal portions, which may be seen lying loosely connected with 
the extremity of the digit by the nail-folds or the distal attachments ; 
(b) when but a few of the nails either of the hands or the feet are 
involved. In this partial form the great toe is most often attacked. 
In some of the recorded cases 3 the general health seems not to have 
been impaired. Often, however, the patients are victims of grave 
neuroses or of wasting diseases. In a middle-aged man under our 
observation who had been for a long period of time subjected to se- 
vere mental strain in connection with his business, all the nails of the 
fingers and toes were separated from their proximal attachments and 
held in place solely by slender distal attachments. The nail-plates 
in some other cases on record were apparently normal ; at times they 
are both discolored and misshapen. 

Onychomadesis (Gr., owf, nail: and fiaBi^co, to pluck out. Alopecia 
Ungualisj Defluvium Unguium ; Onychoptosis). — Total and so- 
called intermittent shedding of the nails occurs, as in the 
partial form, in connection with systemic affections of a severe 
grade. At times the nails are all shed with the skin of the palms and 
soles as after scarlet-fever of severe type, in generalized alopecia 
areata, in some renal diseases. Falcone 4 and others report recurrent 
inflammatory disorders in which not only the nails but the hairs were 
shed in successive attacks. Some of the patients thus affected were 
syphilitic. In a case recorded by Charles White 5 a dystrophic process 

1 Loc. cit. 

2 Case cited by Heller, with illustration, p. 136. Die Krankh. d. Nagel, etc. 

3 White, J. C." D., 1896, xiv., p. 220; also those cited bv Heller, Mracek's 
Hdbch., 1907, Bd. iv., ii.. p. 559. 

4 Gaz. d. osped. Milano, 1887, viii., p. 156; Giorn. Ital. d. Malate. Ven. e. d. 
Pella, 1887, p. 206. 

5 J. C. D., 1896, xiv., p. 220. 



ACQUIRED DISEASES OF TEE NAILS. 993 

occurred in the nails and hair of four generations of subjects. JSTicolle 
and Halipre 1 reported thirty-six individuals in six generations, where 
atrophic and other nail changes coexisted with scanty, friable, and 
readily epilated hairs. In a patient examined by us, similar changes 
were determined in a child who had never experienced an eruption 
of teeth. 

Onychorrexis (Gr., owl;, nail; 'pvfa, fracture. Schizonychia, 
Onychoschisis lamellina symmetrica, "Reedy nails"). — Splitting 
of one or all of the nail-plates usually in longitudinal lines, occa- 
sionally transversely to the long axis of the digit, affects in in- 
conspicuous degree many persons. When exaggerated, lines of 
fracture occur obviously in atrophic depressions between somewhat 
raised ridges, the plates being eventually split clean through to the 
matrix. In a male patient under observation, a single plate of the 
middle finger of one hand persistently and for years split from the 
free border to a point near the proximal fold. In other cases the 
nail-plates are lamellated, the separated strata of the nail-substance 
becoming easily detached. The lamellae, as in a case recorded by 
Ehrmann 2 are commonly roughened, " worm-eaten " in appearance 
and discolored. These conditions may coincide with systemic infec- 
tions but in some instances occur as strictly local sequels of malnu- 
trition, as after trauma. Transversely directed furrows in the nail- 
plates are the frequent and perhaps invariable consequences of im- 
pairment of nail-nutrition either systemic or local. One can often 
date a previously occurring fever, relapses of fever, nervous shocks, 
attacks of sea-sickness, and even enforced confinement to the bed 
as during treatment for fractures and dislocations, after careful ex- 
amination of the nail-plates, exhibiting these transverse furrows at 
different levels. 

Leukonychia (Gr., Xev/co?, white; 6vv%, nail. LeuJcopathia Un- 
guium., Achromia Unguium, Albugo, " White Spots," Flores un- 
guium, " Gift-spots," Canities Unguium; Fr., Decolorization des 
Ongles). — "Whitening of the nail-plates either in totality, or, more fre- 
quently in points, spots, streaks, or bands is not rarely encountered 
chiefly in young subjects upon the nails of the fingers. At times but 
one or a few nails may exhibit a single or several points of decolora- 
tion; in other instances every nail is the seat of numerous spots or 
bars, some occupying the larger portion of the plate. 

The causes of this anomaly are obscure. In some cases, as in 
those described by Longstreth, 3 Shoemaker (I. c), and Giovannini, 4 
this condition was apparently related to nervous or systemic dis- 
orders. Traumatism of the proximal portion of the plate as in the 
operations of the manicure are believed to be responsible for some 
cases. In others the leukonychia concurs with patches of vitiligo in 
other regions of the body surface. 

1 Annales, 1895, s. iii., vi., p. 675. 

2 Monatsh., 1904. 

3 Trans. Coll. Phys. Phil., s. 3, viii., p. 113. 

* Eef orm. Med., Naples, 1891, vii., pi. 2, p. 865. 
63 



994 DISORDEBS OF THE APPENDAGES. 

The pathology of the change is not clear. It is without question 
in some young subjects a strictly physiological condition. By Hel- 
ler and others, it is believed that the white spots are due to the 
entrance of air into the nail-cells, an opinion enforced in a few 
instances by artificial production of the spots after nicking of the 
nail. Heidingsfeld supposes the anomaly to be due to failure of 
proper keratinization of some of the nail-cells. 

ONYCHAUXIS. 

(Gr., ow!;, nail ; avt-io, to grow.) 
(Hypeeteophy of Xail; Oxychogeyphosis.) 

Hypertrophy of the nail may involve one or more of the organs of 
both hands and feet, either as an idiopathic or symptomatic affection. 
The nails may be augmented in length, breadth, or thickness ; and 
changed in shape, density, color, or texture. The term onychogry- 
phosis is restricted by most English authors to the condition in 
which twisted and otherwise contorted anomalies of nails are thus 
produced. 

Compensatory Onychauxis in Embarrassed Circulation. — Decid- 
edly the most common of all the hypertrophies of the nail substance 
with production of sub-ungual keratoma, are those associated with and 
etiologically strictly dependent upon circulatory changes in the hands 
and feet. 1 

The circle of relationship between stimulation of the vaso-motor 
nerve centres, abnormal intra-capillary pressure, sweating of the 
hands and feet, and keratomatous alterations in the palms, soles, 
and nails is not difficult of recognition once the chain of events has 
been carefully studied. Whatever the ultimate cause, whether a 
toxine acting primarily upon nerve centers or upon the constitution 
of the circulating fluids, the clinical fact remains that hyperidrosis of 
those organs the most distant from the heart, ultimately produces in 
one form or another, a condition of onychauxis. Seeing that hyper- 
Trophy and atrophy of the nail-substance frequently go hand in hand, 
in order to intelligently appreciate this sequence of events, it is neces- 
sary to describe in this connection a first grade of the change, which 
belongs rather to the atrophic than hypertrophic disorders of the 
nail, viz., 

"The Egg-shell Nail." — This condition, described by me, 2 
though not directly related to hypertrophic increase of the nail-plate 
is intimately associated with nutritional alterations consequent upon 
embarrassment of the circulation. The patients exhibiting these pe- 
culiarities have been mostly young women, a few men, the former 
commonly in delicate health, the latter for the most part in the 
gouty state. 

1 Cf. Hyde and McEwen, " On the Relation of Certain Dermatoses to each 
other and to changes in Vascular Equilibrium." J. C. D.. 1904, xxii, p. 547. 

2 J. C. D., 1906, xxiv., p. 145, with illustrations in color. 



ONYCHAUXIS. 995 

The nails of both feet and hands are usually involved and sym- 
metrically, being thin, with a distinct tendency to upward thrusting 
of the free border after leaving the nail-bed. This free portion is 
abnormally whitish in hue and suggests the pinkish-white color of the 
inside of the shell of the hen's egg. Usually the nail-bed as distin- 
guished through the semi-translucent plate, is irregularly shaded in 
empurpled or whitish streaks. The nails of the toes especially, often 
exhibit exaggeration of the transverse curve. 

These patients are all, in various grades, victims of well-marked 
hyperidrosis of hands and feet. We have had under observation two 
patients, mother and daughter, each having hands and feet charac- 
teristically wet and cold, with nail-plates altered as here described. 
The toe-nails are usually sodden, and if cut sufficiently short to pre- 
vent the upper thrust of the plate seem to be sunken in the folds. 
The circulation in all cases is impeded. With or without distinct 
cardiac disease there is commonly gout, special sensitiveness to 
narcotico-stimulants (tea, coffee, tobacco, etc.) or anaemia of various 
types. 

Onychauxis with Keratoma and Hyperidrosis (Tylosis of ihe Matrix 
[Crocker]). — This condition is apparently a more pronounced grade 
of the symptoms represented in the " egg-shell nail." These organs in 
both feet and hands are tilted upward and away from the long axis of 
the digit ; they are commonly thickened, discolored, unusually curved 
transversely, and the subungual space is choked with poorly formed 
corneous material. This last may be in an infective state from the 
presence of organisms. The hands and feet thus affected are in- 
variably the seat of hyperidrosis in various grades. At times the 
skin of these parts is merely unusually damp ; in other cases it fairly 
drips with moisture. 

The corresponding keratoma-stage of the skin develops in mild 
type, in the form of a horny ring about the heel, about the distal 
limits of the metatarsus, over the palmar faces of the toes, or over the 
palms and palmar faces of the fingers. In some cases the skin of the 
entire palm and sole is converted into a dense, dirty-yellowish plate 
of corneous consistency, at the borders of which spreads a pinkish or 
reddish halo from passive hypersemia. In one of our cases casts of 
the foot were regularly shed. A well-marked variant of this com- 
plexus of symptoms is displayed when the keratomatous change in- 
volves the entire matrix pushing the nail uniformly upward; or, as 
in Unna's classical case, forming a sub-ungual tumor buckling the 
plate upward and producing finally an onycholysis by longitudinal 
splitting. In yet other cases the characteristic clubbing of the 
fingers due to embarrassed circulation results — and on these, gry- 
photic, more or less distorted nails grow, some curving unusually 
toward the palmar face of the digit, some transversely or longitudi- 
nally ridged. Lastly, in extreme cases, the nails are seen to be un- 
usually dense with a natural polish like that of ivory, empurpled in 



996 DISOEDEES OF THE APPENDAGES. 

hue, surmounting clubbed fingers bathed in " icy " moisture and pas- 
sively congested. 

All these conditions are expressions of an effort on the part of the 
skin of the hand and foot, and of the nails of these organs as well, 
to protect a constantly moistened, and therefore abnormally vulner- 
able surface, from the effects of maceration. These processes operate 
under the impulse of the law of compensation which produces hyper- 
trophy of the heart in an effort to overcome resistance in certain 
valvular diseases of that organ. All these patients have damp, often 
excessively wet hands and feet. In all, the keratomatous modification 
of both matrix of nail and epiderm of palm and sole (the feet more 
frequently than the hands by reason of their greater distance from 
the heart) is an effort toward protection of unduly vulnerable be- 
cause abnormally macerated tissue. The living foetus in utero is 
protected from maceration by the vernix caseosa, a derivative from 
the epitrichium ; the living hand and foot are fully protected from 
maceration during hyperidrosis, only when the compensatory kera- 
toma-process is complete. 

Non-Compensatory Onychauxis. — Hypertrophy of the nails, not 
due to the compensating effort recognized above, may produce changes 
in the nail scarcely to be distinguished from the others. The nail-plate 
may be increased in all dimensions, uniformly or partially ; the thick- 
ened nail wholly or in part may exhibit conical upward projections ; 
its borders may infringe upon the nail-folds to the extent of producing 
there inflammatory changes ; the onychogryphotic claw or talon may 
result, projecting in an ill-shaped contorted mass beyond the free bor- 
der of the digit, and this with either softening or hardening of the nail- 
substance. The nails are commonly dull-colored, opaque, yellowish- 
brown, or dirty-blackish in hue. They are often ridged, rugous, or 
furrowed ; and tilted to one side or upward in recurving lines. The 
matrix and the soft parts about the nails may be inflamed. The nail 
of the great toe, by reason of its projection and size, is most often 
thus involved. 

The causes of non-compensatory increase in the bulk of the nail 
may be purely local, and such as induce irritation of the matrix. 
Pathologically this process may be declared in small-celled infiltration 
and the other phenomena of inflammation. The pressure of ill- 
fitting stockings, shoes, or gloves ; filth ; neglect ; and the exposures 
producing ("professional ") trade-dermatitis of the hands, may be in 
turn responsible for the condition. 

The nail hypertrophies of most common occurrence in connection 
with cutaneous disorders are considered under the separate titles for 
each. 

Onychia (Onychitis) (Gr., owf; } nail) is the resultant of inflam- 
mation of the matrix or folds of the nail ; and may be produced by 
any of the causes capable of exciting inflammation in other regions 



ONYCHAUXIS. 997 

of the integument. Trauma, the pyogenic microorganisms, foreign 
bodies beneath or within the nail-plate, or parasites — may excite 
inflammation of the soft parts about the nail sufficient to produce dis- 
tortion, fall of the plate, ulceration, and even digital gangrene. 

Onychia Maligna, whether occurring in children or adults, since the 
date of modern methods in diagnosis and therapy, has become prac- 
tically unknown. It may be due to struma, syphilis, tuberculosis, 
septicaemia, or any infectious process. Commonly an ulcer forms at 
the border of the nail, which gradually becomes necrotic in floor and 
edge. A severe phlegmonous process complicates some cases. In a 
few instances we have recognized that chronic ulcerations in the 
proximity of the nail were the result of chancroidal infection. 

Paronychia {Panaritium, Whitlow) is that condition in which an 
infection of either nail-fold or matrix (commonly septic, though all 
the infections may here operate) spreads to the surrounding tissues 
with tense painful swelling of the soft parts of an entire digit, in- 
ducing eventually suppuration, necrosis, and at times even exfolia- 
tion of the bone of the involved phalanx. The disorder is one prop- 
erly belonging to the domain of surgery, and commonly requiring 
surgical treatment. 

Syringomyelia {Morvans Disease, Analgesic paralysis with whit- 
low, Fr., Panaris analgesique) . — In this disease a succession of 
whitlows is associated with analgesic symptoms. The phalanges often 
fall into necrosis ; and other painful or destructive cutaneous symp- 
toms concur. The disorder is supposed by some authors to be a 
modified lepra. 

Unguis Incarnatus {Ingrowing Nail) occurs when an edge of the 
nail-plate impinges abnormally upon the soft parts in the vicinity 
and excites irritation. The ingrowth may occur to such an extent as 
to bury the edge of the plate deeply in a sulcus or ulcerated furrow 
on one side or the other of the soft parts where it operates precisely 
like a foreign body. Often an exquisitely tender, granulating wound 
results requiring surgical relief. The condition is one most often 
occurring in the feet, and particularly in the great toe, because of 
pressure-effects from the coverings of the feet. 

Pterygium (Gr., irrepov, a wing). — The fold of the epidermal 
structure, which in health furnishes the proximal border of the nail- 
plate may advance to a greater or less extent over the plate. In 
adult life, this advance may be due to radiotherapeutic treatment of 
the fingers when the nails are exposed to the ray. In some cases the 
condition is the pure result of neglect of hygiene of the nails. In 
others it may result in a considerable deformity. Heller describes 
it as at times congenital, the nail of the big toe being set as if in a 
cap. The treatment is by hygiene of the nails and the use of the 
cuticle knife. 

Hang-nails, " Ag-nails " (Ger., Nietnagel; Fr., Envies) originate 
from tags of the lateral nail-folds, detached mechanically and torn 
upward. At times the rift penetrates deeply into the sulcus by the 



998 DISOEDEBS OF THE APPENDAGES. 

side of the nail, leaving thus an ample atrium for infection with 
microorganisms. This may be the first step toward the production 
of a grave onychia terminating in exfoliation of the distal phalanx. 
In yet other cases chancres form in the part and syphilis follows. 
Biting and picking of the nails is a frequent cause of these appar- 
ently trivial affections. The treatment is by aseptic dressing, protec- 
tion by sealing up the small wound, and in severe cases, excision. 

Subungual Haemorrhage is believed by Unna to be responsible for 
many otherwise unexplained cases of shedding of the nail. In some 
instances the haemorrhages are microscopic and appear only on sec- 
tion of nail-tissue. In other cases minute reddish or reddish-black 
specks become visible beneath the plate. In extreme cases the en- 
tire matrix becomes blackish from effused blood. The nail is shed 
when the process is sufficiently extensive to produce separation of the 
plate from the bed. Subungual haemorrhages occur after trauma ; in 
scurvy ; in haemophilia ; and in rare disorders of the nervous centres 
(epilepsy). Removal of the plate may be required in surgical cases. 

Subungual Tumor-formation occurs rarely. Dr. Shepard 1 reports 
a subungual chondroma. Hutchinson, Jr., 2 recognized an epitheli- 
oma in this situation ; Kraske, cited by Shoemaker, a sarcoma. We 
have seen a number of corns growing beneath the plates. Heller 
gives details of other subungual tumors recognized by different au- 
thors including papilloma, fibroma, leiomyoma, endothelioma, angi- 
oma, telangiectases, and angio-sarcoma. 

MORBID CONDITIONS OF THE NAILS INDUCED BY 
CUTANEOUS DISEASE OF THE EXTREMITIES. 

Eczema. — There is no eczema of the nail apart from an inflam- 
matory process affecting the soft parts in juxtaposition. In pro- 
portion as eczema is one of the most frequently occurring of derma- 
toses, do nail-disorders develop in cutaneous affections. Further, as 
most of the eczemas of the hands and fingers result from the occupa- 
tions of adult life, so are the nail-symptoms of eczema rare in 
children. 

When the parts adjacent to the nail-plates are the seat of an 
eczema, the latter are well-nigh invariably changed, losing their nor- 
mal color, and becoming discolored, dirty-yellowish in hue, furrowed, 
" worm-eaten," split in various directions, and furrowed. The chief 
change is a marked interference with nutrition. Many of the changes 
noted are secondary (as in the eczematous skin), the sequels of 
traumatism, friction, etc., operating upon a weakened surface. 
Eczemas practically limited to the finger-tips with nail-changes, occur 
often in workers in chemicals (e. g., in physicians, chemists, pho- 
tographers), in bar-tenders, laundry-workers, grocers, confectioners, 
and the like. In right-handed persons, the right hand is commonly 

1 Trans. Amer. Med. Assn., 1901, p. 138. 

2 Trans. Path. Soc. Lond., xxxvi., p. 468. 



MORBID CONDITIONS OF THE NAILS. 999 

most involved and the most employed parts of that hand (thumb, 
index, and the adjacent fingers in proportionate measure) show the 
character and grade of the local irritation. 

In these cases the symptoms of an inflammatory process affecting 
the outlying skin are usually distinct (redness, serous exudation, in- 
filtration, crusting, and at times pustulation and undermining of the 
epidermis). 

Psoriasis.. — The nails of the hands and the feet, one, several, or all, 
may be slightly or extensively changed in psoriasis. Most commonly 
there is a concurrent psoriasis of the general integument; but in 
rare cases the nails only are involved. There are several types of this 
localization. 

In the most common form the first symptom of a variation from 
the normal occurs in a distal portion, as distinguished from many of 
the eczematous changes in the nail which spring from the root. In 
this initial stage, the margin of one or more nails near the free bor- 
der loses its natural hue; the edge of the plate is visibly loosened 
from its attachments; and a thin, granular mass interposes between 
the damaged portion of the nail and its bed. The plate at this point 
being friable may either remain in place by reason of its attach- 
ment to the sound portion or it may break away. Patients usually 
pare off this portion before it is presented for examination. The 
process slowly advances upward to the root of the nail on one or both 
sides. As a rule the nails attacked seem to be indiscriminately se- 
lected; in other cases, however, there is symmetrical involvement of 
all the nails of both hands and feet. 

In what has been termed the " pure type " of psoriasis of the 
nails (Consomption dartreuse, of Alibert; psoriasis punctata un- 
guium) the process is less common and rather more conformable to 
that observed in tegumentary lesions. Multiple, pin-head-sized, and 
smaller punctate lesions, often rather regularly disposed, represent 
points of softening of the nail-substance where after desquamation 
of the horny material, equally minute sunken depressions are left in 
the plate, a condition which has been likened to the exterior surface 
of a thimble. When the process is both exaggerated and diffused, a 
deep transverse furrow, or groove, spreads across the plate which 
on either side of this rainure may be normal. 

In many cases of psoriasis the changes when well advanced are 
difficult to classify, the picture presented being that of numerous 
lesions due to malnutrition and fracture. " Worm-eaten," pitted, 
friable, and discolored nails, some split, some fractured, may, on the 
digits either of hands or feet, leave a crumbling-edged, well-attached 
stump, the distal quarter or half the plate missing; the exposed 
matrix covered with an imperfectly formed horny epiderm. 

In many cases where psoriasis affects the nails there is well- 
marked sub-ungual keratoma which may proceed to the point of par- 
tially detaching the nail from the bed, though the former is not often 



1000 DISOBDEBS OF THE APPENDAGES. 

actually shed. In exceptionally severe cases, the nails are greatly 
thickened, distorted, dislocated, or destroyed. 

Other dermatoses, in which the nails are secondarily affected usu- 
ally as complications only of the original process, are the several 
forms of pemphigus, dermatitis herpetiformis, epidermolysis bul- 
losa hereditaria, pityriasis rubra pilaris, and pityriasis rubra. In 
most of these disorders the nail changes (thickening, thinning, 
discoloration, subungual haemorrhage, loosening, and dehiscence) are 
resultants of the general disorder. In all type-cases of pityriasis 
rubra the nails are involved, being usually dislocated from the bed 
and often shed. In the early stages of the disease, the changes in color 
and nutrition of the nails are well marked. 

Etiology and Pathology. — The chief causes of acquired diseases 
of the nails not parasitic in origin are: (a) Associated with general 
disorders of the economy — embarrassment of the circulation, central 
disorders of the nervous system, renal and other visceral affections, 
the fevers (exanthematous and other), the infectious granulomata 
(lepra, syphilis, tuberculosis), and malnutrition from whatever 
cause; (fc) Associated with cutaneous diseases and those largely 
limited to the hands and feet — eczema, psoriasis, pityriasis rubra, 
traumatism, pressure, occupations involving immersion of hands or 
feet in water, and exposure of the latter to the action of chemical 
agents, heat, and cold. 

The morbid process excited in most cases, whatever the cause, is 
inflammation of nail-walls, nail-folds, or the matrix, and a conse- 
quent small-celled infiltration with eventual hyperkeratinization or 
dekeratinization of the horny substance of the nail. Many of the 
resulting deformities such as crumbling, fracture, dislocation, or 
shedding, are due to secondary accidents occurring in weakened nail- 
substance. Leuconychia, whether due to traumatism admitting air 
to the nail-cells, or to failure of keratinization from another cause, is 
at times an achromia that is purely physiological. Unna believes 
that the admission of the air is rendered possible by weakness of the 
nail-cells. 

Unna has ascribed many of the changes in the nail to mechanical 
compression, whereby a trough-like depression occurs in the nail-bed, 
high and narrow ridges resulting from the consequent proliferation 
of the prickle-layer, the nail-plate being thus freed from the bed 
below and forced to rise abruptly over the new-formed layer beneath. 
As all these changes have been observed where no compression had 
been exerted, the explanation is not wholly satisfactory. 

Treatment. — The treatment of the diseases of the nail grouped 
above is often the same, whether the lesions be congenital, acquired, 
atrophic, hypertrophic, or traumatic. The indications are always, as 
far as practicable, to set aside the remote or immediate causes of the 
affection. In circulation embarrassments, the narcotico-stimulants 



MORBID CONDITIONS OF THE NAILS. 1001 

(tobacco, alcohol, tea, coffee) and the indiscriminate use of sweets 
should be abandoned; and in the gouty, overfeeding is harmful even 
with an appropriate dietary. In the anaemic and asthenic, ferrugi- 
nous preparations, cod-liver oil, and tonics in general are indicated. 
The internal administration of arsenic advocated by some authors, 
should be advised only in exceptional cases, as the metal has been 
followed by keratomatous changes in the hands, feet, and nails. 

In all circulation-embarrassments, the feet should be kept as dry 
as possible, stimulating alcoholic lotions being applied morning and 
night, e. g., 

^ Benzoin., tinct., 3v; 201 

Glycerin., Sijss; 10 1 

Spts. vin. rect., 1 ^a Siij ; 901 
Aq. ros., / J J ' ' 

Sig. External use. | M. 

The feet should then be carefully dried and a powder thoroughly 
dusted over and between the toes, e. g., 

* ssriSst'} -*« 2 °i 

Acid, tannic, 3ijss; 10| M. 

Sig. External use. 

Modifications of these applications may be employed as required also 
over the hands. 

In all cases the toes and fingers need careful protection, and 
suitably adapted covering. Woolen and fleece-lined gloves are to be 
avoided. The operations of the manicure are to be omitted in many 
patients, with especial reference to the avoidance of leuconychia. 

In many of the atrophic disorders of the nail, the nail-folds and 
soft parts adjacent require shampooing with the tincture of green 
soap, after which one of the simpler pomades may be applied (zinc- 
oxid; bismuth; lead oleate, etc.). In some cases it is well before ap- 
plications are made to soak the digits in weak alkaline solutions 
(bicarbonate or biborate of sodium). 

In surgical cases (ingrowing toe- and other nails, paronychia, 
enormous gryphosis, etc.) surgical treatment, even in cases removal 
of the nail, is necessary. Many of the milder cases of ingrowing nail 
may be relieved by thinning with a file the middle portions of the 
plate, lifting the ingrown edge away from the fissure or ulcer by 
insinuating a pledget of cotton beneath and between, and appropriate 
pencilling of the irritated portion of the nail-fold with a weak silver 
solution followed by diachylon salve. 

Kinsman's method 1 ensures disinfection by hydrogen dioxide, 

after which a drop of a solution of cocaine is applied followed by 

Monsel's solution which produces retraction of tissue. A dressing of 

gauze is applied over all and the application renewed every second 

1 Hardaway, 1. c. 



1002 



DISORDERS OF THE APPENDAGES. 



day. Piirckhauer scrapes away the nail-tissue softened in a forty 
per cent, caustic potash solution, repeated as required until the 
softened plate can be lifted away from the ulcer and excised. 

The treatment for all conditions of the nail associated with der- 
matoses of the neighboring parts, is that of the affected skin. The 
various lotions and unguents employed in eczema, psoriasis, etc., are 
usually applicable to the nails. Ichthyol in pomade and lotions 
(preferably the latter) in the strength of 25 to 50 per cent. ; 2 to 5 
per cent, solutions of argyrol or silver nitrate ; white precipitate 
salves ten to fifteen grains (one-half to one gram) to the ounce (30.) 
of equal parts of cold cream and vaseline — are all of approved value. 
Dubreuilh advises in these cases an application of two parts of 
chrysarobin and one-half of resorcin, to ten each of lanoline and lard. 

The wearing of rubber gloves and cots is of use in all cases where 
protection of the nails is demanded. 

ONYCHOMYCOSIS. 

(Gr., bvv!-, nail, and fiv/a)g, mushroom.) 

The diseases of the nails due to invasion by vegetable parasites 
are much less frequent than cutaneous affections of similar origin. 
It is, however, accepted that this group of diseases is much more 
common than is generally believed. A single nail of one hand or 
foot, not rarely several, have exhibited morbid symptoms year after 



Fig. 204. 




Tinea trichophytina unguis 



year, and only at the last moment the exact nature of the change has 
been recognized. It is undetermined whether ringworm or favus of 
the nails is more common in this country. 



ONYCHOMYCOSIS. 1003 

Onychomycosis Trichophytina. — (Tinea trichophytina unguis; ring- 
worm of the nails. Fr., Onychomycoses Ger., Schimmelpilzmykosen 
der Ndgel.) Ringworm of the nails is an affection of extreme rarity. 
The effective parasite is most often the trichophyton megalosporon 
ectothrix (Saboraud), derived from the animal kingdom, though 
transferable also from man to man. There may be coincident ring- 
worm of the body or the parasite may attack one nail only, or several. 
After invasion of the organ, the plate becomes changed in color, 
consistency, and shape, the process beginning commonly in the an- 
terior border of the lateral fold. After infection of the nail-bed and 
matrix the nail becomes friable and breaks away irregularly from its 
attachments; there is often subungual debris of cells; and the hypho- 
mycetic invasion extends in longitudinal stria? toward the lunula. 
In other cases, puncta, split and furrowed spaces, dull-whitish, yellow- 
ish, brownish, and even blackish in hue, form at first deeply, later 
superficially ; and finally the anterior portion of the plate is cast and 
a stump is left in situ near the lunula. Onychauxis and onycho- 
gryphosis may result. There may or may not be coincident ringworm 
of the skin. 1 

Onychomycosis Favosa. — (Tinea favosa unguium; Favus of the 
nails. Fr., Onychomycose favique, Favus des ongles.) In favus of 
the nails the effective parasite is the achorion of Schoenlein, usually 
implanted on the nails by auto-infection from scutella. 

According to Unna the rarity of involvement of the nail-plate 
(as distinguished from the trichophytic nail) is due to surface- 
catarrh of the nail-bed. The nails become yellowish in hue ; subun- 
gual masses of cells form though no true scutella ; a dry, dirty-whitish 
powder, constituted of scales, forming both beneath the free border 
and beneath the attached plate. The latter is often raised from its 
bed by the fungus multiplying in anaerobiosis, limiting its in- 
vasion largely to the subungual parts. Long parallel lines of fungous 
growth may occasionally be recognized running beneath the plate in 
the prickle-layer, which may be raised, split, and thickened by the 
morbid process. Unna found the papillae generally thickened. 

Treatment. — In the treatment of both trichophytosis and favus of 
the nails, it is first necessary to remove as far as may be the horny 
substance which interferes with the penetration of a parasiticide. 
The plate should be first scraped and then anointed with some sub- 
stance having power of penetration such as the mercuric oleates, ten 
to twenty per cent, or stronger ; bi-chloride of mercury solutions ; olive 
oil and pyrogallic acid equal parts (Dubreuilh) ; solutions of iodine 
and iodide of potassium, fifteen grains (one gram) of the first, to 
half a drachm (two grams) of the second, dissolved in a litre of dis- 
tilled water (Saboraud). Leistikow (quoted by Hardaway) advises: 

$ Pyroeallol., 5i; 4 

Naphthol., 3ss; 21 

Hydrare;. ammon., gr. xv; l| 

Guaiaei tinct., fvijss; 30 1 M. 

1 Cf. Kavogli, J. A. M. A., 1907, July 27, p. 308, with four illustrations. 



1004 DISORDERS OF THE APPENDAGES. 

Harrison after scraping the nail, applies on lint one part of the 
iodide of potassium in four each of liquor potassse and distilled water, 
for fifteen minutes, after which a one per cent, solution of the bi- 
chloride of mercury in equal parts of spirit and water is kept in con- 
tact with the part for twenty-four hours. This method is advocated 
by Radcliffe-Crocker. Sulphurous acid freshly opened or an aqueous 
solution of the hyposulphite of sodium one part to six or ten mopped 
over the nail after application of dilute acetic acid, are often effective, 

AFFECTIONS OF THE NAILS DUE TO SYPHILIS. 

Changes due to Hereditary Syphilis. — In congenital lues the 
nails are less often affected than in the acquired forms of the disease. 
In both the process may assume the onychia type. In the former 
the resulting onychia is often a part of a specific dactylitis, the earliest 
lesion being a papulo-pustule at the margin of the nail, which bursts 
and leaves an ulcer extending to the matrix and surrounding soft 
parts. The phalanx on which the nail is implanted is the seat of a 
painful osteitis, becomes club-shaped, and the ulcer when fully formed 
presents the characteristics of specific tissue-loss in general, with 
everted edges, sloughy floor, and indolent infiltration of the skin in 
the vicinity. In other cases a chronic inflammatory process affects 
the soft parts about the nail, and the plate undergoes consequent 
changes, losing its polish and becoming dirty-yellowish in hue, thick- 
ened, friable, and furrowed. 

In Vajda's case, cited by Shoemaker, a speckled appearance of 
the nail first appeared, due to splitting of the young nail-substance 
into undulating lamellae, a " wavy arrangement of the nail-cells " cor- 
responding. There was enormous massive thickening of the nail as- 
sociated with hypertrophy of the papillae of the bed. 

Changes due to Acquired Syphilis. — Chancres. — Digital chancres 
most often occur in persons whose vocation requires handling of the 
infected ; we have had under observation one case in which a finger 
was inoculated during a blow on the mouth of an infected antagonist. 
Chancres of the finger are often seated in the nail-folds, partly in 
consequence of the frequency of hang-nails in that region, partly be- 
cause of the exposures incidental to the use of the digits. 

The chancre is usually single and begins as an indolent painless 
nodule involving the nail-fold, developing into a distinctly indurated, 
circumscribed, dull-reddish, exuberant mass. The tumor-like projec- 
tion usually ulcerates superficially; though not many cases are ob- 
served where there is uninterrupted evolution of the lesion, as the 
surgeons, midwives, and others commonly infected, have usually cau- 
terized, excised, or otherwise treated the sore. Some of them suffer 
simultaneously from sepsis, and aside from the accompanying epi- 
trochlear and axillary adenopathy, develop febrile temperatures, have 
axillary abscesses, and suffer greatly in health before the syphilitic 
process is distinctly recognized. 



PLATE L1V 




\ 



Syphilis of the Nails. 



AFFECTIONS OF TEE NAILS DUE TO SYPHILIS. 



1005 



In yet other cases a wide margined, florid, and exuberantly gran- 
ulating fungous mass springs from the nail-fold, capped with a san- 
guineous ulcer the nature of which is long unsuspected. 

Syphilis of the Nail-plate {Syphilonychia sicca; Friable onychia; 
Scabrities unguium syphilitica. Fi\, Onyxis craquele). 

In this condition the plate may be attacked in whole or in part, 
and in the latter event with definite contour of the involved area. 
The distal portion is commonly first involved, the horny plate losing 
its polish, becoming dull-reddish or yellowish-white in color, friable, 
cracked, thickened, roughened, and fissured. The nail-folds may be 
secondarily infiltrated and scaling. In some cases the nails are con- 
siderably thickened ; in others, pin-head-sized, necrotic, sharply de- 
fined points open to the matrix — the condition strongly resembling 
the similar change seen in psoriasis. One or several of the plates 
may be shed in a painless process, though prompt amelioration may 
occur under treatment. 

Syphilis of the Nail-bed and Matrix (Paronychia syphilitica ulcer- 
osa). — The paronychia due to syphilis is the more frequent of the 
nail-symptoms of that disease ; and may first attack the nail-wall or 
fold which then becomes dull-reddish in hue, infiltrated, and scaling. 

Fig. 205. 




Onychia and paronychia occurring in conjunction with a generalized pustular 
syphiloderm. 



After persistence the plate begins to show the changes seen when the 
latter is primarily attacked. The process is indolent and may ter- 
minate before ulceration sets in, under appropriate therapy. 

In other cases a papule, pustule, or an infiltrated and indurated 



1006 DISOEDERS OF THE APPENDAGES. 

nail-wall, breaks down with ulcer-formation, attacking the border of 
the nail and extending beneath the plate, which undergoes the sec- 
ondary changes already described. In severe cases the nail after 
turning a greenish-black hue is dislocated to one side or shed, and 
the entire matrix becomes the seat of an extensive and spreading 
ulcer. The phalanx becomes swollen, clubbed, and painful ; and 
abortive attempts at new nail-formation may be recognized.. Taylor 
describes a rapid necrosis beginning with a brilliant, diffuse redness 
of the entire phalanx in which the nails are destroyed " as if struck 
by a blight," resulting in grave ulceration with lymphangitis and 
adenopathy, the entire fore-arm becoming reddened and swollen due 
to a sequestrum of the embedded portion of the dead nail. 

Treatment. — Energetic treatment of the systemic condition is 
required in all luetic diseases of the nails. The special mode of such 
treatment depends as a rule upon the time which has elapsed since 
infection ; but the existence of a well-marked nail-lesion of undoubted 
syphilitic character should always point to the urgent need of reme- 
dies directed to the correction of the toxic disorder. As a rule most 
of the diseases of the nail due to syphilis are both chronic in course 
and rebellious under even energetic remedies. 

In most of the dry and non-ulcerative affections shampooing of 
the nails should be practiced daily. Where scraping or filing of the 
nails is required for the purpose of removing crumbling tissue, a 
previous soaking in liquor potassse, fifty per cent, solution, in distilled 
water, may be required. At night a pomade should be applied con- 
taining mercurial ointment, one part to two or three of lanoline oil, 
kept in place by a cot worn during the hours of sleep. For this may 
be substituted white precipitate one part to fifteen or thirty of cold 
cream salve. The sulphur salves in ten per cent, strength with the 
red sulphuret of mercury added in the strength of ten decigrammes to 
thirty of salve basis, are often efficient. 

In ulcerating nail disorders the treatment of the attacked parts is 
very largely that of ulcerations elsewhere. The strong caustics once 
advocated are now much less frequently applied. Soaking in bi- 
chloride of mercury solutions, one to one thousand is preferable ; and 
when granulations are present, pencilling^ with a ten per cent, or 
stronger solution of argyrol or silver nitrate. Often a saturated solu- 
tion of pyoktanin blue in distilled water may be advantageously 
painted over the ulcer which after it is dried is dusted with europhen 
or iodoform. 



CLASS X. 

DISEASES OF THE TROPICS AND WARM 
COUNTRIES EXHIBITING CUTANE- 
OUS LESIONS. 1 



The diseases exhibiting cutaneous lesions which occur as well in 
warm climates as in the tropics, are here considered in a separate 
group, chiefly for the convenience of the reader. These affections 
are attracting the special interest of American physicians apart from 
their pathological features, first, because they occur to such an extent 
in the colonial possessions of the United States lying within the 
tropics; and second, because in several of the states of the union, cli- 
matic conditions, especially in the summer season, are those of tropi- 
cal countries. 

HYPERiEMIC AND INFLAMMATORY DISORDERS. 
LICHEN TROPICUS. 

(Miliaria, "Heat Eash," Prickly Heat, Eczema Solare, Red 
Gum, Strophulus; Fr., Miliaire; Ger., Schweissflechte.) 

In tropical and warm countries under the influence of high de- 
grees of temperature, the skin may become the seat of a mild and in 
some cases quite severe disorder which primarily originates in hyper- 
semia of the sweat glands. It occurs commonly in those who have 
been sweating profusely and particularly in persons having a sensi- 
tive skin, such as infants and young adults, invalids, the gouty, and 
the obese. The lesions are usually pin-point to pin-head sized discrete 
but closely aggregated, vesicles, vesico-papules, or distinctly pure pap- 
ules. The sensations are those of pricking, burning, and itching; 
hence the disorder has acquired one of its popular names, " prickly 
heat." 

" Prickly heat " may affect the entire body surface but is common- 
ly most displayed in the parts covered by clothing which are the seat 
of excessive sweating. In tropical countries the morbid condition is 
aggravated in persons of obese habit of body and in those who, coming 

1 Eecent Literature of Tropical Diseases : Scheube, Faleke and Cantlie, Dis. of 
Warm Countries, Phila., 1903; Manson, Tropical Dis., 4th ed., 1907, with 7 
plates and 241 cuts; Jackson, Tropical Dis., Philadelphia, 1907; Ashford and 
King, J. A. M. A., 1907, xlix., p. 471; Eadcliffe-Crocker, VI. Internat. Derm. Con- 
gress; J. C. D., 1908, xxvi., p. 49; Rixey, ibid., p. 63; Fox, Howard, ibid. (Skin 
Diseases of the Negro), p. 67. 

1007 



1008 DISEASES OF TEE TEOPICS. 

from other countries are not habituated to the heat of the climate, 
and who in the effort to counteract its debilitating influences, resort 
to the use of alcoholic stimulants. 

The disease in the heated season of the northern climate is usually 
scarcely more than an annoyance ; but occurring in the tropics it may 
induce a severe inflammatory process in the skin progressing to grades 
of an acute dermatitis, with pustulation when the lesions are infected 
with cocci. 

Etiology and Pathology. — Overheating of the body (from cli- 
matic effects, high temperature of rooms, excessive use of alcoholic 
beverages, sweating under the influence of opium, aspirin, or another 
sudorific) is the usual cause of the disease, resulting in hyperemia 
of the parts about the sweat gland and pore. The question whether 
the process is strictly limited to the epiderm, to dilatation of the ex- 
cretory ducts of the sweat glands, or to the irritation produced by 
the sweat on the surface is not definitely settled. That sudation is 
an essential part of the process is demonstrated in every well marked 
case. 

Diagnosis. — The temperature to which the skin has been sub- 
jected ; the sweating, local or generalized ; the character of the lesions ; 
and their close agglomeration, all point to the nature of the malady. 
In papular eczema there are usually patches and a serous exudate 
which stiffens linen, as distinguished from sweat-moistened clothing, 
which exhibits no such peculiarity. Vesicular eczema rarely ex- 
hibits uniformity and symmetry of the resulting lesions. 

Treatment. — The indications are to remove the cause, as far as 
practicable, and to soothe the irritated skin. Lotions and powders 
are preferable to ointments. The parts may be washed or wiped with 
starch water, almond-meal water, or bran water, and then dried and 
thoroughly dusted with a soothing powder, as equal parts of boric acid, 
zinc-oxid, and starch. The use of soap should be interdicted. The 
bowels should be regularly evacuated, and acidulated beverages, never 
iced, may be ingested in moderate quantity. When medicated lotions 
are indicated, one may use the zinc-oxide and lime water combinations 
which are useful in the treatment of acute eczema. One may also 
employ with advantage black wash diluted one-half with water ; weak 
lotions of carbolic acid, one part to two hundred and fifty, of alcohol 
and water; or of the bi borate of sodium, one part to two hundred. 
When a dusting powder is used talcum, the stearate of zinc, or acetan- 
ilide, one part to thirty each of boric acid and talcum, may be em- 
ployed with advantage. 

PEMPHIGUS CONTAGIOSUS OF THE TROPICS. 

Under this title, Manson, Jackson, and Singh (cited by Manson), 
have described a disorder, non-febrile in character, peculiar to warm 
countries which is here assigned a provisional position in the list of 
tropical diseases. It is admittedly highly contagious, but though the 



PEMPHIGUS CONTAGIOSUS OF TEE TBOPICS. 1009 

Leishman body has been found in its blebs, no special bacterium has 
been demonstrated as efficient in its production. 

The disease exists in Cuba and the Philippines, in the Straits 
Settlements, Madras, Queensland, Japan, and other lands. 

Pemphigus contagiosus is apparently a variant from the impetigo 
contagiosa of temperate countries. The lesions are at the outset ery- 
thematous puncta, developing into vesicles and smaller and larger 
blebs, moderately pruritic, the last springing from a sound skin, tense, 
shining, and with pellucid contents. The serous exudate soon be- 
comes turbid and is confined in a bulla which, after becoming flaccid, 
spontaneously or after trauma bursts, the morbid process advancing 
eccentrically with epidermal exfoliation until an area an inch or more 
in diameter is involved. When self-limited, a pinkish, somewhat 
glazed patch becomes visible covered with a scale resembling tissue- 
paper. At times vesiculation proceeds at the periphery of the in- 
vaded area. The lesions may be relatively few or, more often, 
numerous. 

All parts of the body may be attacked but especially the axillary 
regions and fork of the thighs (eczema intertrigo), where in hot 
weather the distress may be considerable, the skin becoming raw, ten- 
der, and the seat of secondary infections as shown by the occurrence 
of boils. In some of Singh's cases a slough formed. 

Etiology and Pathology. — Streptococci and staphylococci are ob- 
viously responsible for the disease. 

Windisch, 1 in describing his experience with contagious pemphi- 
gus of the tropics developing among the troops of the United States 
during the late Spanish war, clearly identifies the disorder as con- 
tagious impetigo, reporting accidents of infection by the medium of 
clothing, towels, etc., and by intentional inoculation of the secretions 
of the vesico-pustules developing in the disease. Sichel, on the other 
hand, describes several forms of the disorder, two following attacks 
of lichen tropicus ("prickly heat"), one markedly pustular in type, 
the lesions developing in groups, contagion and auto-inoculation not 
being distinctive features of the disorder. In some instances boils 
were present — all the patients had been freely sweating. Munro, 2 
has cultivated what he considers a specific micrococcus (micrococcus 
vesicans) from the contents of lesions in the same disease. His de- 
scriptions agree with those of Manson and Windisch, and yet he be- 
lieves the disorder to be different from impetigo contagiosa because of 
the absence of febrile symptoms which is a point unfavorable to his 
argument ; and also because the lesions occur more frequently on the 
limbs than on the face. The few fatal cases reported by tropical sur- 
geons are evidently results of other toxic agencies such as drink, filth, 
and exhaustion. 

Diagnosis. — Pemphigus contagiosus is distinguished from vari- 

1 J. A. M. A., 1900, Jan. 13, p. 77. 

2 Brit. Med. Jour., April 29, 1899, p. 1021. 

64 



1010 DISEASES OF THE TEOPICS. 

cella by the absence of febrile symptoms. The microscope excludes 
mycotic germs. 

Treatment is by strict cleanliness, and the use of bichloride lotions 
(one to one thousand in water) followed by the application of dust- 
ing powders. 

FEBRILE DISORDERS. 

ACRODYNIA.1 

(Gr., anpoq, extremity.) 

(Dengue Fever, Erythema Epidemicum, Cheiropoetalgia, 
Rheumatismus Febrilis Exanthematosus, Rheumatismus 
Febrilis Epidemicus, Arthrodynia, Boquet, Bou-bou, Knock- 

ELKOORKS, PlAXTARIA.) 

Acrodynia is an acute, infectious, epidemic disease accompanied 
by articular and muscular pains, digestive disorders, and by the exhi- 
bition of eruptive symptoms, the affection occurring for the most part 
along the coast-line of warm countries, more particularly in the south- 
ern parts of Europe and America, including the West Indies, in Asia 
and Africa, and also in the Philippine and Hawaiian Islands. 

Symptoms. — There is commonly a prodromal period lasting from 
a few hours to two days, characterized by twinges in the joints, by 
gastro-intestinal and nervous symptoms, by general depression, and 
by a feeling of malaise. 

Often, however, the disease begins with suddenly occurring chills 
followed by febrile temperatures (103°-106° F.), remittent rather 
than intermittent in type, by headache, accelerated pulse, and charac- 
teristic pains in the larger and smaller articulations, especially in 
the knee-joints, the muscles at the same time being often exquisitely 
tender and the seat of pain. The popular name, " dandy fever " 
(dengue), is supposed to be derived from the oddity in the gait of suf- 
ferers from the disorder. 

The Initial Rashes of the disease are of the order of the toxic 
erythemas (maculations of the surface due to vasomotor disturbance) 
most conspicuous in the facial region and lasting only for from one 
to five or six hours. At the same time the eyelids become puffy ; and 
there may be coincident lachrymation, photophobia, secretion from the 
nares blocking at times the external orifices, injection of the conjunc- 
tival and pharyngeal membranes, and dysphagia due to tumefaction 
of the tonsils. 

1 Bibliography : Manson, Tropical Diseases. London, 1900, p. 195; Scheube, 
Falcke, and Cantlie, Diseases of Warm Countries, Philadelphia, 1903, p. 38; Brun, 
Bull, de l'Acad. de Med., 1893, xxx., p. 227; Davidson, Hygiene and Diseases of 
Warm Countries, 1893, p. 323; von Diihring, Monatshefte, 1890, x., pp. 16 and 128; 
Forrest. Amer. Jour. Med. Sci., 1891, lxxxi., p. 329; Hirsch, Handbuch der hist, 
geog. Pathologie, 1881; Leichtenstein, Nothnagel's Specielle Pathologie u. Thera- 
pie, Wien, 1896, iv., p. 197; Jacquet. La Prat. Derm., i., 1900, p. 261; Bodros, Eec. 
d. mem. de Med., Chir. et Phar. milit., xxxi., s. iii., 1875, p. 428 (describing an epi- 
demic) ; Ollivier, Bull, de l'Acad. de Med., 1888, p. 617; Alibert, 2d ed., Paris, 
1833; Unna, Eealencyclop. d. ges. Heilk., 4 AufL, abstr. Monatsh., 1908, xlvi., p. 
518. 



ACBODYNIA. 1011 

With these symptoms there may be severe or slight salivation, a 
coated tongue, jaundice, albuminuria, insomnia, and other signs of 
grave systemic disturbance. 

Defervescence commonly occurs about the fourth day, the symp- 
toms then rapidly losing their severity and distinctive features. 

Terminal Exanthem — the so-called secondary, eruption of the 
malady — though in some cases absent, occurs usually between the 
third and sixth day of the disease, with or without further pyrexic 
symptoms, with evolution of macules, though there may be vesicles, 
blebs, pustules, or wheals, chiefly over the face, hands, forearms, thighs, 
and chest, though it may be both symmetrical and universal. The 
commonest form of the exanthem is that in which isolated, slightly 
raised, dull-reddish, pea-sized spots appear which may coalesce and 
later become purplish-brown in hue. Manson states that where there 
is marked coalescence, the islands of sound skin produce, at first sight, 
the impression that they constitute the eruption, a species of pallid 
exanthem on a scarlet ground. The lesions have been described as 
resembling those occurring in measles, scarlatina, urticaria, roseola, 
lichen, etc. The palms and soles are oftener of a brilliantly vivid 
hue. The subjective sensations awakened are pricking and burning. 
Simultaneously, there is adenopathy of the cervical, axillary, and 
inguinal glands usually temporary in duration. The exanthem may 
endure for a few hours only or for several days, and may recur after 
complete or partial disappearance. 

Desquamation, slight and furfuraceous, occasionally with shed- 
ding of large flakes, may follow during from two to three weeks and 
be accompanied by severe pruritus. 

The subsequent course of the disease is toward a convalescence 
often interrupted by severe recurrences of pain in one or more joints 
or muscles. Beside the adenopathy named above, there may be pro- 
found physical prostration, furunculosis, orchitis, albuminuria, and 
cardiac complications. 

Etiology and Pathology. — Dengue belongs to the ^category of the 
exanthemata in general, the essential factors in which have been rec- 
ognized so rarely. " Mobile granules " have been found by Hunt in 
blood freshly removed from patients: also in bouillon infected with 
their breath. The disease is contagious ; is transmitted most often to 
individuals living on the coast-lines by the medium of ships and trav- 
ellers ; is relatively rapid in its spread ; and is one communicable to at- 
tendants and physicians. The virus of the disease is believed to be 
capable of transmission through the medium of the soil and the cloth- 
ing. It is favored by high atmospheric temperatures, but conditions 
of sex, race, age, and occupation seem to be of no etiological im- 
portance. 

In four post-mortem examinations of the dead made by Nogue, 
there were lesions of the lungs and of the brain (meningitis with 
adhesions, and sero-purulent infiltration of the pia mater). Chomel 
and Eatmier believe that the disease is due to such changes in the cer- 



1012 DISEASES OF THE TROPICS. ■ 

eal foods consumed, as have been alleged efficient in the production 
of pellagra both in this country and in Italy. Certainly in all well- 
marked cases the diagnosis when practicable is to be made, between 
the two diseases named and grave ergotism. It may be doubted 
whether the lines of distinction between these several morbid condi- 
tions can be carefully drawn. 

Diagnosis. — The affections with which the disease is most liable to 
be confounded are the exanthemata. The characteristic muscular 
and articular pains of dengue, occurring both during and after the 
attack, with the special peculiarities of the exanthem, must be relied 
upon for a recognition of the disease. 

Erythema multiforme is less often accompanied by fever and 
pain. 

Treatment. — As the affection is one which accomplishes a cycle of 
evolution and involution, the treatment is that indicated by the gen- 
eral condition of each patient, including a light diet, rest, the antipy- 
retics, and opiates when needed for relief of the pain. The erup- 
tive symptoms are to be treated, if at all, by emollient baths, and 
soothing dusting powders. 

Prognosis. — The prognosis is in general favorable, the very young 
and old offering the most unfavorable chances of recovery. 

PARASITIC DISEASES OF ANIMAL ORIGIN. 

ANKYLOSTOMIASIS.! 

(Gr., a}/(//of, a bundle; arofia, mouth.) 

(Uncinariasis; Hook-worm disease; Doch miosis; Tropical 
chlorosis; Dirt-eater's anjemia; Mountain anaemia; 
" Ground-itch.") 

The disease has been recognized in Egypt, southern Europe, 
Japan, Australia, the East Indies, Ceylon, South America, and else- 
where ; but has attracted special attention in consequence of its prev- 
alence in the United States and to some extent in Porto Rico, where 
about 30,000 patients have been treated, and in the Philippine Is- 
lands. It is believed that annually thousands acquire the disease in 
the United States especially in Virginia, Xorth and South Carolina, 
Georgia, Florida, Alabama, Louisiana, Texas, Mississippi, Missouri, 
and Tennessee. 

Ankylostomiasis is a progressive anaemia occurring in man after 
invasion of the intestinal canal by a blood-sucking parasite, the Nec- 
tator americanus (Ankylostomum americanum; AnJcylostomum duo- 
deriale; "hook-worm "). 

1 Ashford and King, J. M. A., 1907, Aug. 10, p. 471. Smith, C. A., J. M. A., 
1906, Nov. 24, p. 1693 (3 illustrations). liber die Loosssche Lehre, betreffend die 
Einwanderung der Ankylostoma-Larven durch die Haut, Tenholt-Bochum, Zeitschr. 
f. Medizinalbeamte, 1905, Nr. 4, abstr. Monatsh., 1905, xli., p. 409. Uber den 
neuen Infektionsweg der Ankylostomalarve durch die Haut, Schiiffner-Deli-Sumatra, 
Centralbl. f. Bakteriol. u.s.w., Bd. 40, Heft 5. abstr. Monatsh., 1907, xliv., p. 393. 
Uber das Vorkommen des Ankylostoma in der Haut, Dubreuilh-Bordeaux, La presse 
med., 1905, Nr. 30, abstr. Monatsh., 1905, xli., p. 409. 



PLATE LV 




Elephantiasis Telangiectodes of the Upper Lip and Portions 
of the Face. 



FILARIASIS. 1013 

This parasite has two pairs of ventral labia and one dorsal pair 
with a tooth which has given the name to the worm. Access to the 
human body, as determined by Looss, in 1804, is obtained rarely 
through the digestive canal ; in 96 per cent, of patients through the 
skin, chiefly through the cutaneous follicles. Schaudinn has con- 
firmed the observations of Looss by the production of ankylostomiasis 
in monkeys, after spreading a watery suspension of ankylostoma 
duodenale over the shoulder-blades. 1 Properly shod individuals 
almost never contract the disease. After penetration of the body 
a long train of systemic symptoms may be induced, including not 
only the characteristic anaemia but also grave disorders referable to the 
digestive, circulatory, and nervous systems, in both acute and chronic 
manifestations, death resulting in severe attacks of the malady. 

The cutaneous symptoms occur in from a few minutes to half 
an hour after exposure to the encysted larvae, beginning with pruritus 
followed by redness, tumefaction, papulation, and vesiculation. In 
favorable cases there is no pustulation, but after extensive invasion, 
pustules and even rebellious ulcerations develop. The lower ex- 
tremities which are often swollen, may exhibit extensive scarring 
after healing occurs. The diagnosis depends largely upon discovery 
of worms or ova in the stools ; and the treatment is chiefly by 
anthelmintics including male fern, thymol, beta-naphtol, and oil of 
eucalyptus. 

FILARIASIS. 

(Lat., filium, a thread.) 

(Elephantiasis Arabum, Pachydermia, Bucnemia Teopica, Ele- 
phant Leg, Barbadoes Leg, Cochin-Leg, Spargosis Fibro- 
Areolaris; IIypersarcosis ; Sarcoma Mucosum. Fr., Mal 

de Cayenne.) 

Filariasis is a disorder largely of tropical countries as a conse- 
quence of the invasion of the human body by the filaria sanguinis 
hominis, three different species having been determined to be the ef- 
fective agents in the production of the morbid phenomena, viz., the 
filaria sanguinis hominis diurna, nocturna, and perstans. These 
varieties of the nematode worm are thus differently named from var- 
iations in their periodicity and constancy of occurrence, one ranging 
the blood chiefly at night; a second chiefly in the day-time; and a 
third more or less constantly at all hours. The invasion of the body 
in the modes described below may be followed in the subjects of 
filariasis by no morbid symptoms ; in others, changes are induced of a 
serious character, chiefly by reason of obstruction of the lymphatic 
channels. 

Symptoms. — As the lymphatic vessels may be obstructed by path- 
ological changes where filaria are not present, and as the resulting 
symptoms may be similar if not identical, it is obvious that the clin- 
1 See also Castellani, Brit. Med. Jour., 1908, Feb. 29, p. 494. 



1014 DISEASES OF THE TROPICS. 

ical features presented in these different cases (filarial fever, abscesses, 
hypertrophy of glands, of limbs, of genitalia, of mamma?, and of other 
circumscribed portions of the skin) may be the same. In the pages 
which follow these symptoms, for convenience, are described in a 
single group. 1 

A more or less circumscribed hypertrophy of the skin and under- 
lying structures, may affect any portion of the body, but especially 
the lower extremities, the external genital organs of both sexes, the 
inguinal regions, and, more rarely, the upper extremities, mammary 
region, the buttocks, parts of the head (ears), and with rarity the 
tongue. 

The disease is more common in the tropics 2 where it is usually 
of parasitic origin; but sporadic cases are of occurrence in all coun- 
tries, and are not very rarely seen in portions of the United States. 

The most frequent seat of elephantiasis is the lower extremity of 
one side, where the foot, the leg, or also the thigh of the same limb, 
may enlarge. The penis and scrotum of men, the labia and clitoris 
of women, the upper extremities, the face, the ear, and portions of 
the trunk likewise may become involved. 

The disease is at times insidious in its approach, and gener- 
ally chronic in its career, but may be ushered in with severe rigors, 
prostration, delirium, and fever. Usually, localized inflamma- 
tions precede, as a cellulitis, an erysipelas, or a dermatitis, with 
or without involvement of the lymphatic vessels or glands. At the 
same time there is a condition of general fever (elephantoid or filarial 
fever), to which succeeds a defervescence, with abatement of the local 
inflammation, its sequels becoming manifested in a more or less per- 
sistent oedema of the part lately inflamed. After intervals of days, 
weeks, or months the pyrexia recurs with still greater involvement of 
the swollen tissues, which, with each access of fever, increase in 
volume and gain in density. When the elephantiasic condition is 
fully developed, the skin is tense, glossy, and blanched ; or wart-cov- 
ered, ichthyotic, pigmented in various shades; its follicles patulous, 
its glandular structures either hypertrophied or atrophied, its hairs 
thinned and roughened, the nails correspondingly changed (ony- 
chauxis), with loss of lustre. Pressure upon the cedematous part is 
followed by slight pitting, but the tissue beneath is felt to be brawny 
and indurated. The parts beneath the skin are increased perceptibly 
in volume, especially the subcutaneous tissue ; and the circumference 
of a limb thus diseased may be many times larger than that of its fel- 
low. Lymphangitis is usually declared by painful, cord-like, linear 
indurations of the part, associated with adenopathy of the nearest 

1 Cases of non-filarial elephantiasis occurring in temperate latitudes have been 
reported by Bernstein and Price (following peritonitis), Brit. Med. Jour., 1907, 
Mar. 16. p. 617; MacGregor, ibid., 1898, p. 1597; Fowler, Brooklyn Med. Journ., 
1897, Feb.; Lake, Chicago Med. Becord, 1905. Dec; Southam, Brit. Med. Jour., 
1902, May 3 (gigantic enlargement of right lower extremity, with illustration) ; 
Rogers, Med. Becord, 1900, July 28. 

2 Manson, Brit. Med. Journ., 1894, June 2, p. 1186. with illustration. 



FILABIASIS. 1015 

ganglia. In older cases the skin loses its glabrous aspect, and exhibits 
eczematous, verrucous, papillomatous, seborrhoic, and even ichthyotic 
changes. Pigmentation even to a blackish tint, may ensue; scaling, 
Assuring, and furrowing are common ; and the accumulation of al- 
tered sweat and sebum in these depressions is the source of an offen- 

Fig. 206. 



Elephantiasis scroti. 

sive stench. During the course of the disease almost all the elemen- 
tary lesions of the skin may be displayed : macules, vesicles, papules, 
tubercles, pustules, blebs, ulcers, crusts, scales, excoriations, and fis- 
sures. Warty growths form, as large as those seen in ichthyosis hys- 
trix, and in some cases reddish-colored tumors spring from the hyper- 
trophied integument. 

When fully developed in the lower extremity, the unwieldy limb, 
increased threefold and more in bulk, with the foot, ankle, and leg 
massed into one huge, cumbrous cylinder, bears a striking resem- 
blance to that of the elephant, from which circumstance the malady 
first received its name among the Arabs. Locomotion then is im- 
peded greatly or is rendered impossible. Not less striking is the sim- 
ilar deformity of the genital labia of women or the scrotum of the 
male, the latter at times hanging below the knees even as far as the 
ankle (Fig. 206). 

The penis disappears in rugous folds, and the urine passes along 
a gutter formed of skin transformed into quasi-mucous membrane. 
As a consequence of the fissures and excoriations which form, the 
lymphatic channels may be opened finally, and a true lymphorrhoea 
result. 



1016 



DISEASES OF TEE TEOPICS. 



Subjectively, the disease may be regarded as productive of less 
discomfort than would be suggested by its formidable features. Pain 
is experienced occasionally, and during the exacerbations accom- 
panied by pyrexia there is corresponding malaise. The chief sub- 
jective sensations are those induced by weight and consequent tension, 
inseparable from the enormous masses of hypertrophied tissue. 

In elephantiasis of the scrotum there are frequently symptoms 
of irritation, both systemic and in the vicinity of the affected part 
(nausea, vomiting, inguinal pain, and adenopathy, epididymitis, ef- 
fusion into the sac of the tunica vaginalis, inflammatory swelling of 
the spermatic cord, and at times hernia). In some cases vasculariza- 
tion of the surface (telangiectatic elephantiasis) is a prominent fea- 
ture. The form described below as ncevoid elephantiasis may belong 
either to the same category, or to others in which there is lymphan- 
giectasis ("lymph-tumors," " lymph-scrotum ") , and these may be 
due either to lymphatic obstruction or to the parasite described later 
as of etiological importance in this connection. 

Lymph-scrotum (Varix Lymphaticus, Ncevoid Elephantiasis). — 
Lymph-scrotum may be the precursory stage of elephantiasis of the 
same part. Commonly an attack is announced by the occurrence of 

Fig. 207. 




Elephantiasis of the foot and leg. 



fever, soon followed by erythematous redness of the scrotal envelope, 
followed by vesiculation and the development, of blebs. The burst- 
ing of these is the source of the continuous drain which ensues. The 
scrotum becomes more or less enlarged, and though soft to the 
touch, is the seat of multiple, often numerous, lymphatic varices, 



FILABIASIS. 1017 

which on puncture or spontaneous rupture give exit to a rapidly coag- 
ulating lymph or chyle. Several ounces of a clear or lactescent fluid 
may escape in an hour, and the discharge persist to the point of pro- 
ducing grave physical exhaustion. Inguinal and femoral adenopathy 
may be present. Often there are recurrent chills, fever, erysipelas, 
abscesses, and the localized inflammations occurring in elephantiasis 
of other organs of the body. 

Etiology. — The causes of elephantiasis as explained above are dif- 
ferent in several of the disorders designated by that name. The most 
common factor, in the countries where elephantiasis is prevalent, is 
the presence in the body of Filaria sanguinis hominis, which can be 
recognized in the blood of the majority of natives of such countries. 
Living filarise have been demonstrated in blood-vessels placed under 
the microscope. 

The parasite is sought for best late in the evening, a drop of blood 
being transferred to the microscope-slide by the usual methods, the 
glass having previously been dipped in water, to each 30 c.c. of which 
have been added three drops of a saturated alcoholic solution of fuch- 
sin. The embryo is recognized as a transparent, serpent-shaped, col- 
orless organism exhibiting great activity by wriggling motions, which, 
however, do not greatly change the position of the worm. One ex- 
tremity of the parasite is abruptly rounded ; the other for about one- 
fifth of the entire length tapers to a fine point. The worm is en- 
closed in a delicate, limp, structureless sheath, or sac, longer than 
the contained worm. Manson believes that the function of this en- 
velope is prevention of the puncture of the tissues of the animal in 
which it lives, prior to future development in an " intermediate host." 
Delicate transverse striae can be recognized in the musculo-cutaneous 
layers of the entire length of the animal. A shining triangular V- 
shaped patch usually can be seen at a point about one-fifth of the en- 
tire length back of the head-end; and a similar but smaller spot is 
visible at a short distance from the end of the tail. These points are 
believed to be connected with the evolution of the embryo into the 
mature parasite. The head-end is capable of projection and with- 
drawal from a delicate prepuce having six lips, or hooks, a short thin 
fang being often shot out from the uncovered cephalic extremity. 

The periodicity of filarise is well marked in most cases under ob- 
servation, the embryos swarming in the circulation at night and dis- 
appearing during the day, or the reverse. Manson estimates that at 
midnight there may be forty or fifty millions of embryos simultane- 
ously circulating in the vessels, all of which may disappear by 8 or 9 
o'clock in the morning, the hours of activity being reversed when the 
filarial subject habitually sleeps during the day and is awake at night. 

The intermediate host of the filaria is the mosquito (the females 
of some family of the genus Culex fatigans) , which after feasting on 
the blood of a filarial subject are found to have the stomach gorged 
with living embryos. The viscidity of the ingested dehydrated blood 
prompts the filarise to struggle until freed from their sheaths, when 



1018 DISEASES OF THE TROPICS. 

they begin a distinct locomotion for the first time in their life-history, 
— now entering the thoracic muscles of the insect, and here, as else- 
where in the body of the intermediate host, undergoing in a period 
of from ten to twenty days a metamorphosis resulting in the forma- 
tion of a mouth, an alimentary canal, and a trilobed tail. A consider- 
able increase is now noted in their size. The vast majority then 
pass forward through the prothorax and neck of the mosquito until 
they enter the head, where they lie coiled up close to the base of the 
proboscis, beneath the pharynx and under surface of the cephalic 
ganglia. The parasites may remain in this position until they have 
the opportunity of entering, by the attacks of the mosquito, into the 
body of a warm-blooded vertebrate host, refusing, as shown by experi- 
ments, to quit the mosquitoes which have been fed for long periods 
of time upon bananas. 

Once reintroduced into the human body, sexual maturity is 
reached, fecundation ensues, and in due course generations of embryo 
filarial are poured into the lymph. These passing through any in- 
tervening glands by way of the thoracic duct and the left subclavian 
vein, or by the lymphatics of the upper segment of the body, finally 
appear in the blood. 

Other disturbances due to the same parasite, and only in part 
recognized as elephantiasic, are the lymph-scrotum described above, 
chylous abscess, effusions, and vascular and hypertrophic enlargement 
of tissue and glands in and about tumors of the sort recognized as 
parasitic. 

In other cases different causes are to be recognized. Predisposi- 
tion of races or individuals, heredity, climatic influences, malaria, 
fatiguing labor with the feet and legs immersed in water, and filth 
in connection with "misery," have all been cited as favoring condi- 
tions. To these causes should be added the local disorders especially 
common in the lower extremities that have in cases proved to be points 
of departure of elephantiasic hypertrophy, such as obstruction to the 
blood or lymphatic currents by pressure of tumors, pregnancy, or neo- 
plasms ; ulcers ; cicatrices ; traumatisms by pressure or friction ; 
cutaneous diseases; systemic affections (syphilis, tuberculosis); and 
osseous disease. 

Moncorvo 1 has described congenital elephantiasis after study of 
ten cases, in none of which were filaria recognized. All the infants 
had feeble resistance ; and the parents of some were affected with 
either erysipelas, syphilis, or lymphatic obstruction. 

Pathology. — Even macroscopically the elephantiasic mass is seen 
to be built up of hypertrophic elements representing all the tissues of 
which the part is composed. The knife with difficulty divides the 
homogeneous, whitish, and lardaceous mass, from which on pressure 
exudes a fluid of similar color. The subcutaneous connective tissue 
is found relatively much more enlarged and sclerosed than the epider- 
mis and derma ; though when section is made through the rugous and 
1 Sur la pathog. de 1 'elephant, congenit., Paris, 1895. 



FILABIASIS. 1019 

warty skin described above, all the elements of the papillary layer, 
rete, and stratum, corneum are seen to participate in the changes de- 
scribed in connection with the pathology of verruca. Here and there 
are loculi filled with fluid lymph. The sheaths of the blood-vessels, 
lymphatics, nerves, and the bones, muscles, and aponeuroses are also 
thickened, solidified, and occasionally agglutinated, so as to be almost 
indistinguishable in the mass of uniformly sclerosed tissue. The 
pigmentation of the derma is marked, the nuclei of the connective-tis- 
sue cells are multiplied, and the cutaneous glands intact, hypertro- 
phied in their epithelial linings and investments, or, at a later stage, 
atrophied. 

It is evident that in many cases, as Virchow has pointed out, the 
earliest of the changes to be noted occur in the lymphatic glands and 
vessels, the whitish and yellowish lymphatic fluid which then accumu- 
lates in the tissue resulting from obstruction of the lymph-channels. 
In some of the remarkable cases on record the lymphatic obstruction 
is the prominent feature of the disease, and the elephantiasic enlarge- 
ment is subordinate in gravity to the former condition. Such are, for 
example, the noteworthy instances in which the lymph distends mul- 
tiple cutaneous vesicles, after rupture of one or more of which the 
fluid streams away to a dangerous extent. 

Diagnosis. — The striking deformity which characterizes elephan- 
tiasis will always suffice for its recognition. In the earliest stages of 
the disease, when there is merely oedema or an erysipelatous or eczema- 
tous condition of the skin, it would be difficult, if not impossible, to 
decide as to the future of the disorder, especially in a locality in 
which only sporadic cases occur. A symmetrical hypertrophy of both 
legs and both feet, developing in America, even though described as 
"elephantiasis," should carefully be studied before a diagnosis is 
made of the particular disease here considered. The same might be 
said of elephantiasis of but one inferior extremity. A patient with 
an extensive deforming induration and enlargement of the right leg 
and foot, -accompanied by pigmentation and a well-marked warty con- 
dition of the skin, who had been pronounced the victim of idiopathic 
elephantiasis Arabum, had received a fracture of the upper third of 
both bones of the same leg during the previous year, and had since the 
accident constantly worn a tight bandage encircling the limb at the 
seat of the injury. The deformity rapidly disappeared under the 
application of a roller bandage extending from the toes upward. 

A peculiar and rare, though characteristic, deformity of the labia 
majora of women — most commonly the labium ma jus of one side — 
results from a syphilitic, gummatous infiltration which must be distin- 
guished from elephantiasis. In cases of this kind the history of the 
patient and the relative inferiority as to bulk of the affected organ 
point to the nature of the disease. The syphilitic labium rarely 
exceeds the size of a large fist. 

A gigantic, hypertrophied mass of elephantiasic type is occasion- 
ally to be discovered in the lower extremity of only one side in pa- 



1020 DISEASES OF THE TBOPICS. 

tients who have been for many years the victims of an unrecognized 
and long-untreated syphilis. Even when the leg is many times its 
normal size and weight, and its contour lost in a thickened and rough- 
ened epidermis resembling the bark of a tree, the diagnosis may be 
made by discovering here and there in the depth of the mass circular 
and characteristic scars of healed gummatous ulcers. 

Treatment. — Prophylaxis of filariasis is secured by elimination 
of the mosquito. In the early stage of elephantiasis the febrile con- 
dition of the patient and the localized cutaneous inflammation are to 
be treated by the measures appropriate for the relief of these condi- 
tions. Quinine, especially in malarial districts, is of the highest 
importance. When the elephantiasic development is established, if 
the genitals are involved the knife of the surgeon offers the best pros- 
pects. The result of such interference, both in the genitalia and the 
extremities, has in many cases been brilliant, though the mortality 
of such severe operations is necessarily great. When the lower ex- 
tremity is involved it should be maintained in a horizontal position, 
its ulcers if possible be healed, its excrescences removed, its circum- 
scribed inflammations resolved, and then elastic compression be care- 
fully and skilfully maintained by means of a rubber bandage. The 
toes are first separately enveloped, then the foot and ankle, and lastly 
the leg. The results are sometimes highly satisfactory. Similarly 
the elephantiasic scrotum or labium ma jus requires support and con- 
striction prior to operative interference. 

Ligation and digital compression of the main artery supplying the 
elephantiasic leg have occasionally been followed by transient im- 
provement. Instrumental compression has at times resulted in severe 
ulceration and a reawakening of the erysipelatous affection. Multi- 
ple punctures and incisions, made with a view to giving exit to the 
fluids contained in the mass, have been attended by no greater success. 
The main obstacle in all these surgical procedures is the lymphangitis 
which so frequently complicates the situation. JSTone of them prom- 
ises so well as nerve-stretching, which in a few isolated cases has been 
followed by noteworthy results. Excision of a portion of the sciatic 
nerve has also been followed by satisfactory changes. The use of the 
galvanic current has, when long continued, accomplished resolution 
of engorged masses of tissue. Elastic compression in the horizontal 
position for all cases not warranting nerve-stretching may be regarded 
as the wisest course when the extremity is involved. For the local 
treatment of the pachydermia proper, green soap, mercurial ointment, 
and bathing with hot or cold lotions may advantageously be employed. 
For patients whose disease is acquired in countries where the deform- 
ity is prevalent a change of climate is of the highest importance ; and, 
having in view the social surroundings and habits of most victims of 
the disease, it is scarcely necessary to call attention to the need of a 
proper hygiene, diet, and tonic regimen. 

Prognosis. — The future of a patient may be regarded as most 
favorable when the disease exhibits an early tendency to respond 



TRYPANOSOMIASIS. 1 02 1 

favorably to appropriate treatment, and when circumstances permit 
of a resort to the best therapeutic measures which can be adopted, 
such as change of residence, persistent and careful dressing of the 
affected part, and the removal of any exciting cause of the disease, 
such as a neoplasm, an indurated cicatrix, etc. In the severer cases a 
fatal result may occur early in the disease; but usually life is pro- 
longed, burdened by the inconvenience of the enormous elephantiasic 
mass, in comparison with which the rest of the body often seems to 
serve as a mere appendage. 

TRYPANOSOMIASIS. 

(Gt., rpltnavov, a borer; aufia, the body.) 

Human trypanosomiasis is an affection produced as a consequence 
of invasion of the body by the Trypanosoma gambiense, occurring 
chiefly in the western portions of Africa. The trypanosome is a 
flagellate blood parasite, about 15 to 30 microns in length and from 
1.5 to 2 in width, which is believed to gain access to the system 
through the medium either of the tse-tse fly {Glossina palpalis) or a 
similar insect which may attack the skin. The mode of invasion, 
the life-history of the parasite, and other questions of importance in 
this connection have not been fully determined by laboratory research. 

Symptoms. — The bite of the insect usually produces a point of 
local irritation, followed in the course of a few hours or days by the 
development of irregular and relapsing febrile phenomena. Physical 
and mental lassitude, headache, irritability of the heart, polyadenitis, 
and eventually marked anaemia result. Almost all writers agree that 
the cutaneous symptoms are rarely absent. These eruptive phe- 
nomena include papular and pustular lesions ; and fugitive erythema 
evidently of toxic type, often occurs in circinate patches, some of 
which are from six inches to a foot in diameter, the margins fading 
very gradually into the surrounding normal skin. Stimulation of 
and pressure upon the integument produce vaso-motor distension of 
the cutaneous capillaries. In many cases there is marked oedema 
(skin of penis, abdominal surface, nucha, and face). 

The terminal stages of the disease are those now well recognized 
under the title, Sleeping Sickness, for details of which the reader is 
referred to the standard treatises on the subject. 1 This stage of the 
disorder has thus far been followed by fatal results in an enormous 
majority of all cases. 

Treatment. — Prophylaxis is to be sought by avoidance of the dis- 
tricts where the glossina is found; as also by protection from all 
insects. 

Arsenic and mercury have been thought in some cases to be 
effectual. 

1 See Bogers, Fevers in the Tropics, London, 1908, p. 96. 



1022 DISEASES OF THE TBOPICS. 

DKACONTIASIS.i 

(Gr., dpa,K.6v-M, serpents.) 

(Filaria Medinensis; Guinea-worm Disease; Dracunculus 
Medinensis ; Medina Worm ; Guinea Worm ; Filaria Dra- 
cunculus. Fr., Dragonneau, Ver du Kutegal; Ger., Peit- 
schenwurm; Medinawurm; Holland., Guineesche Draake.) 

The records of the guinea-worm disease extend to a remote an- 
tiquity. It is a disorder due to invasion of the body by a nematode 
parasite, the Medina worm, and occurs almost exclusively in tropical 
countries, more particularly along the West African Coast, in the 
Soudan, Egypt, and Abyssinia ; in Asia, especially in the countries 
bordering on the Persian Gulf, in British India and the Fiji Islands ; 
and in America particularly in Guiana, Brazil, and the Antilles. 

Symptoms. — The lesions due to invasion of the skin by the Dra- 
cunculus medinensis are observed first at the point where the worm 
is about to make exit, which point may be at a considerable distance 
from that where it entered, and the exit may be made after an interval 
of several weeks or months. This approach to the surface for the 
purpose of securing exit is accomplished only when the worm is 
quite mature, at which time it can be felt beneath the surface, suggest- 
ing the presence of a soft cord. After some local sensation of tension 
or of itching, a pea-sized to small-nut or even egg-sized vesico-papule 
forms, superficial or subdermic in situation, which, after accidental 
or intentional rupture, gives exit to a clear serous fluid in which the 
uncolored head of the worm may be recognized. If the fluid be 
turbid, it is believed that the young embryos have escaped from the 
uterus. The head, which is surrounded by a quantity of leucocytes, 
appears either at once or in the course of a brief time, producing slow 
and sinuous movements by alternate contractions and elongations. 
The entire worm and its young may then wholly be extruded in the 
course of a week or more ; or the head may be withdrawn and another 
swelling form at another part of the surface, the first meantime 
closing; or, in unskilfully managed cases, the worm may be torn so 
that the head only is removed, and then a severe lymphangitis with 
inflammatory, suppurative, and even gangrenous symptoms may su- 
pervene, producing, in fact, the train of symptoms now well recog- 
nized in connection with septicaemia. In some cases, however, the 
body may be discharged later than the head, after the mechanical 
separation of the latter, without serious consequences. The escape 
of embryos into the adjacent tissue is regarded also as a grave com- 
plication. 

x Bibliography: Bloch, Allg. med. Ctr.-Ztg., 1899, lxviii., p. 729; Foulkes, Brit. 
Med. Jour., 1898, ii., p. 236; Fox, T., Lancet, 1879, i., p. 330; Harrington, Brit. 
Med. Jour., 1899, i., p. 146; Mackenzie, Ind. Med. Record, 1898, p. 326; Manson, 
Brit. Med. Jour., 1895, ii., p. 1350, and Tropical Diseases, 4th Ed., 1907, p. 667; 
Perrin, Annales, 1896. s. iii., vii., p. 131; Roux. Traite prat, des Mai. des Pays 
Chauds, 1888, iii., p. 553; Scheube, Diseases of Warm Countries, p. 379 (bibliog- 
raphy). 



DBACONTIASIS. 1 023 

The chief sites of exit are the ankle and the foot — particularly the 
heel — but in rarer cases the leg, thigh, buttocks, penis, scrotum, 
hands, trunk, neck, and face may be selected. There is usually but 
one worm in a single subject of the disease, but the number may be 
indefinitely large in persons exposed. 

Etiology. — The precise mode of invasion of the body by the effec- 
tive parasite has not been determined, but it is probable that the 
larvae of the worm or an intermediate host (the fresh-water cy clops) 
may be ingested in the drinking water, after which access is ob- 
tained to the mucous lining of the digestive tract; or that the skin 
may be either directly penetrated by the embryo or indirectly inocu- 
lated through the traumatisms inflicted by such insects as the mo- 
squito or the fly. The fact that nearly two-thirds of all cases occur 
in the foot is not without significance. Harrington observed the dis- 
ease on the backs and loins of water-carriers where the leathern sacks 
come in contact with the body. Young filarial have been seen pene- 
trating the microscopic Crustacea in fresh water, the later ingestion 
of which in drinking-water is supposed to be effective in the produc- 
tion of the disease. 

Persons of both sexes and all ages are liable to be invaded ; but 
the disease is of more frequent occurrence in the rainy season, and in 
male negroes and day laborers. 

Pathology and Natural History of the Worm. — The female worm 
alone produces the disease. It is when mature a yellowish-white, 
cylindrical filament, gradually tapering toward the caudal extremity, 
averaging 60 to 80 centimetres in length and 0.5—1.7 in breadth, the 
body being extremely extensible by reason of the elasticity of its 
cutaneous envelope. The cephalic extremity is rounded and termi- 
nates in an oval, shield-like disk in which is a centrally placed tri- 
angular oral orifice. There is a small papilla on each dorsal and 
ventral edge and six smaller on the borders of the shield. While 
there is a straight intestinal tract extending through the body of 
the parasite, its bulk is composed of an enormous uterus which is 
capable of containing, according to estimates made, between eight 
and ten millions of embryos. 

The embryos without decidua are flattish, possessing a long awl- 
shaped tail, a three-lipped mouth, and a digestive canal. They are 
capable of surviving for a week in water ; and longer in moist earth 
or water polluted with material which provides them sustenance. 
Manson states that the embryos, when they have obtained access to 
the water, transfer themselves to the body-cavity of the cyclops 
quadricomis, fifteen or twenty at a time inhabiting the host, without 
apparent inconvenience to the latter. Soon the exuvium is shed for 
two or three times, the tails drop off, the worms acquire a cylindrical 
shape, and develop a tripartite arrangement of the caudal extremity. 

In from ten to a maximum of fifteen months the maturity of the 
female which has been impregnated is attained, and the parasite finds 



1024 DISEASES OF THE TROPICS. 

its way from muscles or other tissues in which she has been lodged or 
to which she has travelled to the surface of the body. 

Diagnosis. — The diagnosis (to be made in countries where the dis- 
ease is endemic) is based upon the discovery of the worm. 

Treatment. — The usual method of treatment by the natives of the 
countries named is to secure carefully the head when it appears, and 
to tease out the worm very gently day after day until the entire body 
is extracted, securing the accessible portion by winding it about a bit 
of stick or of paper. Continuous irrigation of the wound is both 
recommended and practised where the disease is common. Tincture 
of asafoetida has also been employed to destroy the parasite. 

Manson has protested against winding out the guinea-worm, 
stating that at best this process merely shortens by a few days the 
duration of the treatment in case the parasite is situated properly in 
the tissues without twists or turns, or if it has arrived at a stage of 
life when, having discharged its young, it is ready to come out 
spontaneously. If, as is often the case, the worm is twined and 
twisted among the tissues, and if she is still emitting her young, she 
will resist traction, a process which will result often in rupture. In 
consequence of rupture at this time myriads of young escape into 
the tissues, producing violent inflammation, which is accompanied 
frequently by secondary infection and possibly by sepsis. To deter- 
mine if the worm is ready to come out spontaneously, the open- 
ing of the tumor may be douched for a number of minutes at a time, 
several times a day, by dripping cold water over it. When under the 
influence of this douching the worm no longer emits young careful 
winding out is not objectionable. 

The accepted treatment is that devised by a French naval surgeon, 
Emily. The swelling produced by the worm when she approaches the 
skin and before she has pierced it, is injected in several places with 
a solution of mercuric chloride (1:1000). This kills the worm, 
which may be absorbed subsequently, or if cut down upon a day or 
two later her body can easily be withdrawn. In case the head of the 
worm be already protruding, the solution may be injected directly 
into her body, which is removed easily the following day. A number 
of cases have been treated successfully by this method, and with no 
disagreeable results in the way of pain or inflammation. This 
method also reduces the time of treatment from not less than four 
weeks to the much shorter period of four or five days. 

Prophylaxis is secured by protection of drinking water from 
pollution and by wearing proper covering over the feet. 

Prognosis. — The prognosis is favorable, save in cases in which 
septicemic symptoms develop as a consequence of coccogenous in- 
fection. 



TICK FEVER. 1025 



TICK FEVER. 

(Relapsing Fever; Spirillum Fever; Famine Fever; Rocky 
Mountain Spotted Fever; Black Fever; Blue Disease; 
Pyroplasmosis hominis. Fi\, Tique.) 

Tick, or relapsing fever, is a disorder which under varying names 
has been recognized as of occurrence in all the great continents of the 
earth and especially in Iceland, the Scandinavian Peninsula, Russia, 
Africa, Turkey, China and the United States. {Cf. p. 443.) 

Symptoms. — The disease, which attacks individuals of both sexes 
and all ages, begins with the usual prodromata of febrile accesses, 
chills followed by relatively high temperatures, delirium, icterus, and 
gastro-pulmonary symptoms. An initial pyrexia is followed by a 
first remission succeeded by one or several relapses, terminating 
fatally in about six per cent, of cases. In many patients there are 
cutaneous symptoms developing between the sixth and seventh days. 
more marked in certain epidemics than in others, consisting of labial 
herpes, accompanied by circinate rose-tinted maculations, one to five 
millimeters in diameter, developing at the surface of the trunk and 
extremities. Occasionally the mucous membranes are involved. At 
first the lesions disappear under pressure ; later, they furnish a bluish 
purple marking of the integument. These are followed in three weeks 
by desquamation. 

In the United States the disease has chiefly developed in Montana, 
Idaho, and Wyoming between the months of April and August, the 
eruptive phenomena in the American cases being purpuric in charac- 
ter and at times generalized. Gangrene, especially of the digits, 
scrotum, and ears, has occasionally resulted. 

Ricketts and King 1 have on the whole confirmed the view origi- 
nally advanced by Wilson and Chowning, 2 that the disease is due to 
a hematozoal parasite and transmitted by a species of tick. Tick 
fever has been produced in guinea pigs and monkeys by blood inocu- 
lations ; and one individual of the lower animals has been made to 
infect another by the medium of the tick. The observations of 
Mackie 3 in the Bombay settlements seem to point conclusively to the 
part l^layed by body lice in the transmission of this disease. 

Etiology. — Manson and other writers on this subject agree that 
the nature and etiology of this affection are not yet definitely de- 
termined. 

Treatment. — Prophylaxis is secured by scrupulous personal and 
domestic cleanliness, with the aid of the mosquito net and the burn- 
ing of a night-lamp in countries where insects have nocturnal preda- 
tory habits. 

Treatment is conducted in accordance with the principles of gen- 

1 J. A. M. A., 1906, July 7, Aug. 4. Also Ricketts and Gomez, J. Infect. Dis., 
1908. v., pp. 221-244. 

2 Journ. Infect. Dis., 1904, i., p. 31. 

3 Cf. the paragraphs in this work on Pediculosis. 
65 



1026 DISEASES OF THE TROPICS. 

eral medicine. Quinine was employed with some success in the 
American cases. 

Chigger Disease (Sand-flea bites; Parasite: Dermatophilus pene- 
trans; Sarcopsylla penetrans; Rhynocoprion penetrans; Nigua; 
Chigoe; Jigger; Sand-flea. Fr., Puce sable; Ger., Sandfloh). 

The sand-flea, found originally in tropical America including the 
West Indies, within the last thirty years has appeared in many por- 
tions of tropical Africa and the adjacent islands, as well as in India. 

The sand-flea is a minute, brownish-red, egg-shaped parasite, the 
female of which after impregnation penetrates the skin of man and 
of the lower animals, including rats and mice. The flea attacks the 
skin, in man usually about the toes or near the nails, entrance being 
effected with scarcely painful pricking sensations. Distention of the 
abdomen of the parasite, which may exceed five-fold its original 
dimensions, speedily becomes the source of great irritation. In the 
course of from five to ten days a painful oedema with pustulation fol- 
lows, occasionally accompanied by lymphangitis or severer symptoms 
in the form of gangrenous abscesses. 

The treatment of the disease is by extraction of the flea with the 
aid of a heated needle, whereby it is destroyed simultaneously. The 
resulting wound may be cauterized or dressed antiseptically. 

Prophylaxis in " chigger-regions " is of chief importance and 
secured by sweeping accumulations of dust from walls and floors, 
which should be regularly dusted with an insecticide powder such 
as pyrethrum. 

MYIASIS. 

(Gr., /ivia, house-fly.) 

Joseph divided all cases of infection by larvae of flies into (1) 
myiasis externa, or dermatosa, and (2) myiasis interna, or intes- 
tinalis. 

There are no dipterous insects attacking man only, but the ova 
of several species may be deposited in the skin and mucous mem- 
branes with subsequent development of larvae. According to Geber, 
the ova of several species of Muscidoe and 2Estridce (of the former, 
Lucilia cossar, in America; Stomoxis calcitrans, in Africa; and Sar- 
copliyUa wohlfarti, in Russia; of the latter, Dermatobia noxalis, 
cuterebra, and hypoderma) are occasionally found in the skin and 
subcutaneous tissue. The following species 1 have been reported in 
wounds and in other external affections : Musca domestica, Mnsca 
stabulanSj Calliphora vomitoria, Calliphora erythrocephalis, Lucilia 
ccesar. 

Several specimens illustrating these accidents have been sent to 
the author. The larva? represented in Fig. 209 were removed from 

1 Gilbert. Arehiv, of Int. Med., 1908, ii., p. 226, covering the entire subject, 
from which the data following have been abstracted. 



MYIASIS. 1027 

the body of an infant in Nebraska. The Muscidos (flesh, house, 
stable, dung, and other flies) have unarmed maxillae, and are unable 
to wound the uninjured skin. The pregnant female seeks, therefore, 
to deposit her ova where the larvae, equally unprovided with developed 
jaws, can most readily secure nutriment. Hence, open wounds and 
the tender skins of newborn infants when exposed in the summer 
season, are liable to become the depots of such ova. Larvae of 
Muscidce have also been found in wounds, in ulcers, in the ear, nose, 
and vagina. 

Screw Worm (Chrysomyia or compsomyia macellaria) . — This is 
the larva of a dipterous insect found in all parts of America but es- 
pecially in the tropics and in the Southern States of the Union, pro- 
duced from the ova of an insect laying several hundreds of eggs, which 
may be deposited on the surfaces of exposed wounds and also in the 
nasal and aural passages of persons sleeping in the open air. The 

Fig. 208. 

<3S2B> 



Fig. 209. 
a 




CEstrus : a, the larva, natural size ; b, Larvae removed from the body of a 

some of the segments seen under a lens. child. Of the exact size, after several 

and showing the lines of minute projec- days in alcohol ; a, as seen from side ; b, 

tion ; c and d, the terminal ends of the as seen from beneath. 
insect. (After Abraham.) 

danger is imminent when offensive discharges from these regions in- 
vite the visitation. The white larvae are about three-fourths of an 
inch long, and are formed of twelve segments provided with circlets 
of small spirally arranged spines, which give them the appearance 
of a screw and enables them to burrow deeply into the tissues to which 
they have gained access. 

Yount and Sudler 1 have collated 23 cases seen by themselves and 
others, eighteen of which were instances of nasal myiasis. Two 
deaths were directly traceable to the incursion of the parasites; in 
two others life was shortened; the mortality for all was fifteen per 
cent. ; in the nasal cases alone somewhat more than twenty-two per 
cent. All the patients were attacked out of doors mostly in the nose, 
the discomfort beginning within twenty-four hours after invasion. 
This was speedily followed by severe pain, fever, and foul, often 
haemorrhagic discharge from the nasal cavity. The parts attacked 
may become gangrenous ; bone may be exposed ; and necrotic palatal 
1 J. A. M. A., 1907, xlix., p. 1914, with 3 illustrations. 



1028 DISEASES OF THE TBOPICS. 

perforation, pneumonia, and otitis media may result. Manson 1 calls 
attention to the importance of careful investigation, in countries 
where the worms are found, of all cases of bloody and offensive 
nasal discharges. Prophylaxis is secured by avoiding open-air sleep- 
ing during the sun-lit hours of the days, as also by especially care- 
ful treatment of all nasal and aural discharges and open wounds. 
Curative treatment is by spraying with chloroform, though pyre- 
thrum, turpentine, and carbolic acid also have been employed. 2 

Larva Migrans 3 (Crocker); "Creeping Eruption" (Hyponomo- 
derma [Kaposi ] ; Dermamyiasis linearis migrans cestrosa [Krum- 
berg] ) is an affection, first described by Lee, later by Crocker, Neu- 
mann, Stelwagon, and others, in which a migrating larva (sup- 
posed to be that of a bot-fly, Gastrophelus) , 1 mm. in length with 
ten segments and hooklets and two head-end suckers, burrows in the 
skin and produces a slight elevation of the surface above the cunicu- 
lus, pale rose pink or slightly reddish in hue. Erythema or vesicula- 
tion in a continuous or interrupted bead-like linear lesion represents 
the track of invasion, crusted or fading in the older portion. The 
thread-like line is pushed forward from a fraction of an inch to 
several inches each day. The line may be tortuous or irregular and 
extend over a large part of the body-surface. Black nits are said to 
be found upon hairs near the burrow. In rare cases two parasites 
may be present. Gilbert 4 states that these larvae have been known 
for centuries to be parasites of man. 

Stelwagon, whose description has been followed in these para- 
graphs, corroborates the findings of Sokolow and Samson-Himmel- 
stjerna, which recognize as the starting-point of departure of the para- 
site the regions most exposed to inoculation (hands, fore-arms, feet, 
lower portion of the legs, buttocks, and adjacent parts of the back). 
In his four cases the invasion probably occurred during a visit to 
the sea-shore. 

Treatment is by cauterization of the invaded areas. Stelwagon 
advises cataphoretic applications of mercuric chlorid, two grains to 

1 Loc. cit. 

2 Wirsing, Dent. med. Woch., 1906, No. 23. 

3 Literature: A Case of Creeping Eruption (Lee), H. W. Stelwagon, J. C. D., 
1903, xxi., p. 503; idem, B. J. D.. 1904, xvi., p. 192; idem, J. C. D., 1904, xxii., pp. 
359-362; cf. also his treatise, 1907, 1107 (cut and bibliography to date). Eduard 
Kengsep, Epidermititis Linearis Migrans. Centralb., 1906, ix., pp. 194-199 (the 
writer concludes by giving a resume of the literature of the subject and discusses 
the nomenclature and pathology of the disease). J. B. Shelmire, Eeport of a Case 
of Creeping Eruption, J. C. D., 1905, xxiii.. p. 257. Van Harlingen, Am. Jour. 
Med. Sci., 1902, Sept., (3 cases. 4 cuts). Louis P. Hamburger, Creening 
Eruption: Its Relation to Myiasis, J. C. D., 1904, xxii., pp. 217-227, (1 hist, illus- 
tration. 1 clin. illustration, bibliography). Hutehins, Creeping Disease: Report of 
two cases of larva migrans with special reference to the treatment, J. C. D., 1906, 
xxiv., p. 270. Lenglet and Delaunay, A Case of Larva Migrans, Annales, 1904, s. 
iv., v., p. 107. Moorehead. Creeping Disease, Texas Med. News. 1906, xv., p. 167. 
Xeumann. Fall von, Creeping Disease, Verhandlungen der Wiener derm. Gesell- 
schaft; Archiv, 1906, lxxxii., p. 421. J. E. V. Boas (Kopenhagen), "Larva 
migrans." eine Gastrophiluslarve in der Haut eines Menschen in Danemark, 
Monatsh., 1907, xliv., pp. 505-512, (Eef., 4 illus.). 

* Loc. cit. 



MYIASIS. 1029 

the ounce (.133 to 30.) to the area surrounding the advanced line 
of the burrow. 

CEstrus bovis (Gadbreeze, gadfly). — This insect also may deposit 
its ova in accessible parts of the human body, with the result of pro- 
ducing painful swellings moving from one point to another, which 
may suppurate and discharge the larval contents. Walter Smith, 
of Dublin, 1 has described a case where an ovum deposited in the 
ankle of a twelve-year-old girl moved to the elbow and there dis- 
charged a grub nearly an inch in length. Birdsall 2 describes two 
worms, one-fourth and one-half inches long, and one-eighth of an 
inch in thickness, escaping from between the middle and ring fingers 
of the hand of one patient ; and a second instance where the leg- 
was attacked. The specimens came from Gaboon on the West Coast 
of Africa, the fly (family (E strides) responsible for the mischief 
being reported as attacking the gorilla and the native tribe engaged 
in capturing these animals. 

Cephenomyia.- — Several species of this genus are found parasitic 
in the nasal sinuses of sheep, in which they occasion very severe 
symptoms. Wesley Thompson 3 reported a case in a man in San 
Bernardino, California. The patient, who had previously suffered 
from nasal catarrh, showed an accelerated pulse and fever, the nose 
was swollen and the nares nearly closed with dried blood and mucus. 
Forty larvae were removed. 

The larva of Dermatobia cyaniventris, of this genus is known and 
described under various local names, as the ver macaque (monkey- 
worm), torcel, and in Mexico, moyociul. It is found in South and 
Central America and cases have been reported in the southern portion 
of the United States. It has so frequently affected man as to be- 
come known as the CEstrus liominis, under which title it has been 
frequently described in literature. 

In man, however, the flies are most commonly found developing 
in suppurating wounds and ulcers, and in chronic ear and nose 
affections, where there has previously been considerable discharge. 
In Egypt the larvae have been found in ulcers beneath the eyelid. 

Larvee of this family have also been found in furunculous swell- 
ings beneath the skin, in the vagina of girls and women, especially 
where there has been a discharge. They are even reported to have 
penetrated the cranial cavity from infection of the sinuses or by 
orbital fissure. 

1 Int. Med. Congress — Archiv of Derm., Jan., 1882. 

2 N. Y. Med. Eecord, 1882, Mar. 18, p. 298. 

3 Quoted from Gilbert, loc. cit. 



1030 DISEASES OF THE TROPICS. 

PARASITIC DISEASES OF VEGETABLE ORIGIN. 

MYCETOMA. 

(Gr., i-ii'tajc, a fungus.) 

(Podelcoma, Madura Foot, Morbus Pedis Entophyticus, Ulcus 
Grave,, Endemic Degeneration of the Bones of the Foot, 
Morbus Tuberculosus Pedis, Elephant Foot, Madura 
Disease, Fungus Foot of India, Fungus Disease of India, 
" Egg-foot." Ger., Madurafuss; hid., Perical, Slipada; 
Fr., Mycetome, Pied de Madure.) 

Mycetoma is a localized affection limited to the skin and adja- 
cent parts, due to invasion of the tissues by vegetable parasites, and 
characterized by the production of an unshapely tumefaction of the 
invaded part, which becomes covered with nodules or tubercles for 
the most part permeated by fistulous sinuses. The disease not only 
affects the skin, but also the underlying structures to a variable 
extent. It long was thought to be a malady occurring only in India, 
but more lately has been recognized in China, Syria, parts of Africa, 
and in both North and South America. 

The record of its first recognition on the American continent is 
embodied in the apparently unsupported statements of Ruelle, 1 who 
reports that Collas observed one case at La Reunion, Grail and 
Grand-Mourrel each one case in Guiana, and Layet one in Chili and 
another in Valparaiso. McQuestin saw three cases affecting native 
Mexicans in the Civil Hospital of Hermosillo, and Kemper reported 
a case which for some years was thought to be the first occurring in 
the United States, but a critical examination of the description of 
the acute symptoms presented by his patient raises doubt respecting 
the accuracy of the diagnosis. Parkes reported that he had operated 
successfully upon a patient suffering from mycetoma in the city of 
Chicago. The disease, however, had been contracted in India. 

The first case certainly known to have originated in North 
America in which no question exists as to the diagnosis was reported 
by Adami and Kirkpatrick. • Soon after the appearance of this 

1 Bibliography : Adami and Kirkpatrick, Trans. Assoc. Amer. Phys., 1895, x., 
p. 92. Arwine and Lamb, Amer. Jour. Med. Sci., 1899, cxviii., p. 293. Boyce, 
Hyg. Eundsch., 1894. iv., No. 12. Surveyor, Brit. Med. Jour., 1892, p. 575. 
Carter, Treatise on Mycetoma, or the Fungus Diseases of India, London, 1874. 
Dantec, Le, Arch, de med. naval, 1894, p. 447. Gemy and Vincent, Annales, 1896, 
s. iii., vii., p. 1253. Hatch, Keith, and Childe, Lancet, 1894, p. 1271. Hyde, J. N., 
and Senn, N., J. C. D., 1896, xiv., p. 1. Kanthack, A. A., Lancet, 1892, i., p. 195, 
and ii., p. 169; Jour. Path, and Bact., Oct., 1892. Manson, Tropical Diseases, 
4th ed., p. 760. Paltauf, Intern, klin. Rundsch., 1894, No. 26. Pope and Lamb, 
N. Y. Med. Jour., 1896, lxiv., p. 368. Ruelle, Contribution a 1 'etude de mycetoma, 
Bordeaux, 1893, p. 13 et seq. Scheube, Faleke, Cantlie, loc. cit., p. 552 (full bibli- 
ography). Shah, T. M., Med. Rep., Calcutta, 1893, p. 225. Vincent, Annales de 
l'lnst. Past., 1894, p. 129. Wright, Trans. Assoc. Amer. Phys., 1898, xiii., p. 471. 
Emma Dubendorfer, Ein Beitrag zur Histologie und Bakteriologie des Madura- 
fusses, Archiv, 1907, lxxxviii., Band 1, pp. 3-10, 1 clin. illustration, 4 hist, illustra- 
tions. Clemon, Brit. Med. Jour., 1906, Ap. 21, p. 918. 



PL AliL LV 




Mycetoma of the Foot. 

(From a Painting.) 



MYCETOMA. 1031 

report, in connection with Semi and Bishop, I published the record 
of a case of mycetoma occurring in a native of Iowa who had never 
been outside of his native State before visiting the city of Chicago. 
Pope and Lamb, Wright, and Arwine and Lamb also have published 
reports of cases, with demonstration of the fungus and its subsequent 
artificial cultivation. This record of five cases of Madura foot in 
North America includes the history of four men and of one woman. 

The disease was referred to first by Kampfer in 1712, but was 
differentiated clearly from elephantiasis first by Godfrey in 1843. 
It has been studied carefully since by Ballingall, Eyre, Carter, Kant- 
hack, Bbcarro, Surveyor, Gremy, and Vincent. 

Symptomatology. — Three varieties of mycetoma were once loosely 
distinguished by the color of the morbid material contained in the 
discharge, viz., the black, the red, and the white, or ochroid ; the last 
named the most common, the second the rarest, the black rather less 
frequently encountered than the white. The part principally affected 
in most of the Indian and in the American cases is the foot, and this 
chiefly of persons walking barefoot ; but the hand, the shoulder, the 
thigh, the knee, the toe, the abdominal wall, the scrotum, and other 
regions have been attacked. Simultaneous involvement of different 
regions of the body has never been noted. 

In a typical case the sole of the foot is involved by progressive 
spread of the disease from the site of a trifling traumatism which 
often at first heals and is followed later by the development, near 
the site of the wound, of a rounded, firm, painless, small nut-sized, 
subcutaneous button or nodule which increases slowly in volume and 
later is surrounded by similar lesions. In the course of five to ten 
weeks or more, the tumor softens and bursts, discharging a charac- 
teristic, viscid, " oily," semi-purulent, blood-streaked fluid which con- 
tains minute, roundish (grayish, reddish, or blackish) particles, 
which have been compared to fish-roe. These may be agglomerated 
in pea-sized masses. At the site of each lesion a permanent sinus 
penetrates deeply beneath and is said never to undergo spontaneous 
healing. The repetition of the process by the multiplication of 
nodules and fistulous tracts produces eventually the deformity char- 
acteristic of the disease. The progress of the malady may be ex- 
ceedingly chronic, as ten and more years have been recorded not 
rarely as requisite for its complete evolution. 

In fully developed cases, when the foot is involved, the organ is 
seen to be largely increased in volume, producing without elongation 
an elastic bulging of the parts posterior to the digits over the dorsum 
above, and below over the plantar region, giving the sole a convex 
appearance. The toes may be in forced separation or misdirected. 
Over the tumid parts the skin is beset with numerous pea- to nut-sized 
isolated nodules, elevated to the extent of several millimetres above 
the general level, each pierced with a fistulous channel extending 
from without to the deeper structures. At times these fistulous tracts 
lead only to the soft parts and especially to muscular tissues; at 



032 



DISEASES OF THE TBOPICS. 



others the surface of the bone is reached and the osseous tissue is 
eroded by the growth of the parasite and the coccogenous infection 
which results from long exposure of the parts to the air. It is 
through these fistulous orifices that in different cases exit is given 
to a blackish, fish-roe-like substance, or to a whitish material, or even 
still more rarely, as indicated above, to a reddish substance. 

In place of nodules or papules, the skin may be the seat of 
pustules, of vesicles, of bulla?, or even of abscesses. When but re- 
latively small organs of the body are invaded, such as a finger or a 
toe, it becomes clear that the tumefaction is not due chiefly to a 

Fig. 210. 




Osseous lesions in mycetoma. 



hypertrophy either of the integument or the bones. When the foot is 
affected seriously, the leg above commonly atrophies from disuse. 



MYCETOMA. 1033 

The discharge varies in different eases. In some it is almost 
wholly wanting; in others it is scanty; in yet others exceedingly pro- 
fuse and fetid. It is generally oily or syrupy in character. When 
blackish in hue, the contained granules have been likened to truffles 
or fish-roe ; when of paler hues, it resembles fish-spawn. 

The course of the disease is exceedingly chronic; and while one 
or more nodules have been seen to heal, the mass of the disease per- 
sists until relief is obtained by artificial methods. 

Pain is usually not pronounced; sensibility is maintained; and 
the general health may be undisturbed for long periods of time. 
Death, when it ensues, results from long-continued drain upon the 
vitality of the patient. 

Diagnosis. — In all cases of long standing, the disease is readily 
recognized by the characteristic deformity produced; in certain va- 
rieties of the affection by the escape of fish-roe-like particles ; and 
in all, by microscopic recognition of the parasites present. In well 
defined instances, the nodes or papules externally visible are often per- 
forated with sinuses leading downward to the deeper structures. The 
painlessness of the invaded part is also characteristic. 

Etiology and Pathology. — The disease is caused by invasion of 
the tissues of the body by vegetable parasites. It is probable that the 
parasites secure access to the skin by the medium of a traumatism, 
and the occurrence of a large majority of all cases on or near the foot, 
most often in men and among individuals who have been walking- 
barefoot, lends support to this view. Further, the origin of a few 
cases has been traced to foot-lesions (bruising of the organ with a 
stone and consequent abscess; injury with a pitchfork, a fall on the 
knee, etc. ) ; while the relative freedom of persons who protect the feet 
while residing in the districts where the disease is common, is in 
evidence. The lower class of poor agriculturists, during the twentieth 
to the fiftieth year of life, are most liable to the affection, while chil- 
dren and infants escape. The origin of the disease has not been 
traced to any peculiarities of soil. 

The following is a brief abstract of the classification of the 
fungi responsible for the several varieties of the disease given by 
Brumpt, and cited by Manson : 

1. Actinomycotic Mycetoma: Caused by Discomyces bovis (ray-fungus) (Harz, 
1877). Sulphur-yellow granules, 0.75 mm. in diameter; radiating mycelia in 
felted masses; clubs at ends representing actively growing protoplasm. 

2. Vincent's White Mycetoma: Caused by Discomyces madurse (Vincent, 1894). 
Grains, pin-head to pea-sized, yellowish-white, soft, with mulberry surface; fQa- 
ments, radiating, between which are numerous lymphocytes also arranged in 
radiations. Detached shoots reproduce characteristic structure. Does not attack 



3. Nicolle's White Mycetoma: Caused by Aspergillus nidulans (Eidam, 1883). 
Grains spherical, smooth, pea-sized. The organism attacks bone. 

4. Bouffard's Black Mycetoma: Caused by Aspergillus bouffardi (Brumpt, 
1906). Grains, black, pin-head- to small-shot-sized, mulberry surface, smooth and 
glossy, often surrounded by giant and epithelioid cells. Densely felted silvery 
mycelium with peripheral zone of irregular moniliform threads; dark brown 
interstitial substance. 



1034 DISEASES OF THE TBOPICS. 

5. Classic Black Mycetoma: Caused by Madurella mycetomi (Laveran, 1902). 
Grains, dark-brown to blackish color; composed of white threads 1 to 10 mm. in 
diameter; cement substance dark brown with connective tissue capsule. 

6. Brumpt's White Mycetoma Indiella mansoni (Brumpt, 1906). Grains, hard, 
white, minute, lenticular in shape, one-fourth to one-fifth mm. in diameter; large 
hyphal threads with connecting cement-substance. 

7. Keynier's White Mycetoma: Caused by Indiella reynieri (Brumpt, 1906). 
Soft, white grains composed of densely felted hyphal threads in coiled strands 
terminating in divided chlamydospores. 

8. Bouffard's White Mycetoma: Caused by Indiella somaliensis (Brumpt, 
1906). Grains, white to reddish-yellow, small, smooth, averaging 1 mm. in 
diameter; always found in giant cells; not enclosed in nodules; highly destructive. 

Iii a well-advanced case on section the foot is found to be tun- 
neled in various directions by sinuses which communicate with oval 
or roundish cavities. The latter may be superficial or deep and may 
occupy the soft tissues or the bones, and have a connective tissue 
lining. Here the granules singly or in masses (mulberry-like) are 
found as well as in the neighboring softened tissues. 

In the period of early reactive inflammation, the fungus is sur- 
rounded merely by the results of cell-proliferation ; typical granula- 
tion-tissue, epithelioid cells, and new-vessel formation follow. Some- 
what later plasma cells, giant cells, and amorphous granular masses 
occur and finally degenerative changes attack the entire area. 

The bones when denuded are found to be honeycombed with finely 
carved seams, depressions, furrows, and pits, leaving delicate spicula 
of osseous tissue projecting between the excavations wrought by the 
growth of the parasite. It is possible to find, as Adami suggested in 
the study of his case, intrusive organisms the result of exposure for so 
long a period of time of the deeper tissues to the atmosphere. 

Treatment. — Early in the disease potassium iodide may be em- 
ployed with curettage and packing of the superficial lesions. As a 
rule amputation is the only method of eradicating the disease. 

Prognosis. — As spontaneous recovery does not occur, the prog- 
nosis depends upon the treatment employed. 

ACTINOMYCOSIS OF THE SKIN. 

(Gr., /li'KT/-, and atrlg, mushroom.) 

" Lumpy- jaw." Ger., Aktixomykose ; Fr., Actixomycose.) 

In 1877 Ponfick proved that the disease, first recognized by 
Bollinger in the jaws of cattle was the same as that which Israel in 
1S77 had observed in man. 1 Hartz, judging largely from its mor- 

1 Illustrations: Neumann's Atlas, Plate XIII.; Morris, Lancet, June 6, 1896; 
Pringle, Med.-Chir. Trans., 1895; Kopp's Atlas, Plate LXXV.; Corlett — cut ap- 
pearing in Stelwagon's treatise, p. 1050; Illich, Wien., 1892; Darier et Gautier, 
Annales, 1891, p. 449; Ponfick, Treat. Berlin, 1882; Israel, Treat. Berlin, 1884; 
Skerritt, Amer. Jour. Med. Sci., 1887; Poncet et Berard, Trait., Paris, 1898; 
Bodamer, Med. News, 1889; Crookshank, Lancet, 1898, p. 11; Legrain, Annales, 
1891, s. 3, ii., p. 772; Baracz, Wien. med. Presse, 1889, xxx., p. 6; Ljunggren, 
Nord. med. Arch., 1895; Kopfstein, Wien. med. Eundschau, 1901, p. 21; Mac- 
Cullum. Centralbl. o. Bakliv., 1902, xxxi.; Howard, Jour. Med. Resch., 1903, ix., 
p. 301. 



ACTINOMYCOSIS. 1035 

phological characters, described the parasite as the ray-fungus. 
Maiocchi was first to describe the disease as it involves the skin. 

Symptoms, — In actinomycoses, the parasite commonly gains access 
to the economy by the mouth, especially by the avenue of a carious 
tooth ; and the skin, when implicated, as a rule is involved secondarily. 
Such skin-lesions displayed are more often about the face and neck, 
more particularly the lateral surfaces of the neck beneath the jaw, 
where deep subcutaneous nodes, tumors, or swellings, often firm to 
the touch, livid in hue, thinning at one or at several points after 
involvement of the integument, finally burst, forming fistulous tracts 
and giving exit to a serosanguineous or bloody and purulent fluid, 
containing friable, yellowish or grayish masses in which the fungus 
may be recognized. The orifices of the sinus or sinuses after such 
discharge are usually beset with cutaneous and subcutaneous nodules 
and uneven lumps, some softened, others firm and indurated, usually 
reddish or purplish in hue, tender, painful, and often accompanied 
by pains elsewhere, particularly in mastication, in deglutition, and in 
certain movements of the head on the neck. The outlying skin be- 
comes infiltrated, tumid, empurpled, and boggy. Rarely papilloma- 
tous growths develop. 

The onset of the disease is insidious, and though occasionally 
rapid in its career, its evolution may extend over months and even 
years. The nearer to complete development of the disease the more 
rapid, as a rule, is the oncoming of its symptoms. In exceptional 
cases the malady attacks the fingers, the hands, and other parts of the 
body. Rarely, secondary actinomycosis of the lymphatic glands 
occurs. Pringle reported a case in which large areas on the back, 
lumbar region, and hip were affected secondarily after involvement 
of deeper organs. 1 Lymphatic metastasis is, however, rare, due, as 
is believed, to the large size of the fungus-granules as compared with 
the lumen of the lymphatic vessels. Subjective symptoms may be 
insignificant or be related to the pain and stiffness of the neck con- 
current with the subcutaneous abscesses. 

Diagnosis. — All supraclavicular and submaxillary lesions consti- 
tuted of dark-reddish tumors or swellings, subcutaneous in origin, call 
for scrutiny. Scrofuloderma is to be recognized by the general condi- 
tion of the patient (actinomycosis may occur in vigorous young 
adults) ; by the absence of pronounced gumma and lymphoma 
("gomme scrof uleuse " ) ; and by failure of recognition of the para- 
site, which is not easy of detection. The occupation of the subject of 
the disease (as a farrier, stable-boy, or drover) may furnish a clue to 
the origin of some cases. Care should always be taken, in making a 
diagnosis, to exclude cases of swellings discharging pus, practically 
limited to the skin immediately over the lower jaw, with sinuses 
leading to the bone beneath, in which the disorder is exclusively due 
to a carious fang of one of the lower central or canine teeth. These 
should be relieved by extraction of the offending tooth. 

1 Med.-Chir. Trans., 1895, lxxviii., p. 21. 



1036 DISEASES OF THE TROPICS. 

Etiology and Pathology.- — More men than women are attacked 
as a result of special exposure ; a few of the affected have been occu- 
pied with cattle and horses ; others having carious teeth may have 
been infected by accidents of contact or in the operations of dentistry. 
The subjects are usually young adults, though we have treated a male 
patient over sixty years of age. Cases are on record of transmission 
from man to man, from animals to man, and by traumatism when in- 
animate objects were the media by which the fungus was introduced. 
The affection is communicable by inoculation. In most instances there 
have been submaxillary lesions and carious teeth. The general dis- 
persion of the fungi in the atmosphere, water, and upon the soil is 
held to explain in large measure the occurrence of the disease in 
man. Beards of barley, bits of wood and stone, vegetable fragments, 
etc., have been found in actinomycotic lesions. 

The pathological anatomy of actinomycosis is practically that 
described above in mycetoma. In the most commonly recognized 
type of the disease, the fungus is found in the yellowish or grayish 
masses discharged in clumps from the fistulous tracts and found also 
in sections of morbid tissue. Often there are seen fine interlacing 
threads or filaments radiating from a common center, some con- 
siderably projected above their fellows, many with a bullous expres- 
sion at the tip ('•clubs"). The threads are slender, sinuous, often 
with dichotomous branches and have an external sheath and proto- 
plasmic medulla. The filaments grow rapidly and probably produce 
the disease. Coccus- and bacillus-like cells, regarded by Bostrom as 
spores, are also present. 

Treatment. — The treatment is by surgical procedures, ablation, 
erasion, antisepsis by mercuric chloride. Lugol's solution, boric acid, 
and dressings with antiseptic gauze. Gautier has employed with suc- 
cess an electro-chemical method of treatment, by the use of platinum 
needles and injections of a 10 per cent, potassium iodide solution. 
Two needles are inserted, one connected with each pole of the battery, 
and a current of fifty milliamperes is passed; a few drops of the 
iodine solution are injected during the flow of the electricity, the 
patient being anaesthetized. Before attempting surgical measures 
potassium iodide given internally should be tried, since it has proved 
successful in many cases. Schlange, at the Congress of German Sur- 
geons held in 1890, called attention to the fact that of nearly two hun- 
dred patients under his observation (over half traced since 1886), 
forty were completely cured for more than two years ; and in eighty 
the disease remained limited to the head and neck. After thirteen 
years of involvement one patient at the date of the report was alive. 
All extensive operations for relief of the malady are now abandoned. 
Even actinomycosis of the lungs and viscera is susceptible of spon- 
taneous recovery. Cases apparently hopeless have recovered in five 
and six years. Intestinal complications are grave. Pringle's pa- 
tient improved under potassium iodide. Untreated the disease may 
eventually destroy life after years of an exhaustive drain. 



MYCOTIC DERMATITIS. 1037 

Prognosis. — It was held until lately that the prognosis was favor- 
able only in case of thorough and prompt removal of all diseased 
tissue. In other cases a fatal result was anticipated. 

MYCOTIC DERMATITIS. 
Dhobie Itch (Washerman's itch; Crutch itch; Arm-pit itch). 

The term Dhobie itch is employed very generally in tropical coun- 
tries, more particularly in the Philippine islands, for the designa- 
tion of a group of itching affections of the skin, mostly though not in- 
variably, due to vegetable organisms of the family of the microsporons 
and trichophytons. The popular name by which some of these cu- 
taneous affections are recognized, represents the common belief that 
they are transmitted by the medium of the clothing contaminated in 
the processes of the laundry. We have had several of the cases thus 
designated under our observation the most of them differing widely in 
their etiological origin. 

Stitt 1 calls attention to the fact that the "fulminating" types 
of Dhobie itch are mixed cases of staphylococcic invasion and para- 
sitism due to a mould fungus present. This symbiosis is possibly the 
cause of the severe character of the process. 

Manson calls attention to the severity of all epiphytic affections in 
hot countries and to the distress which they occasion as a result of the 
dermatitis aroused by itching, scratching, friction, and the frequent 
secondary infections producing often boils and abscesses. 

Respecting the groups of epiphytic diseases observed in hot coun- 
tries Manson recognizes a mycotic pityriasis flava as seen in Ceylon, 
which are frequently called Dhobie itch, produced by the Microsporon 
tropicum; a white form produced by Microsporon macfadyeni; and a 
black form seen by him in China (Microsporon mansoni), producing 
black hemispherical forms when cultivated on maltose agar. He 
believes that many cases of Dhobie itch are of the nature of ery- 
thrasma due to the microsporon minutissimum. 

Diagnosis. — The diagnosis is to be established by the microscope; 
the treatment should be that outlined in the chapter of this treatise 
devoted to the several forms of Ring-worm. 

Treatment. — Prophylaxis is to be secured by the wearing of proper 
clothing; by scrupulous cleanliness, and by the free use of borated 
dusting powders. 

Tinea Imbricata. — (Tokelau Ringworm; Burmese, Chinese, or 
India Ringworm; Bow ditch-island or Scaly Ringworm, Lafa Toke- 
lau, Pita, Cascadoe, Gune, Herpes Desquamans, Tinea Circinata 
Tropica, Gogo. Fr., Herpes tonsurans desquamatif.) This disorder 
was portrayed first by Alibert in 1832, and described first in 1844 by 

1 J. C. D., Mar., 1908, p. 107. 



1038 DISEASES OF THE TEOPICS. 

Fox, and has been studied since by Turner, 1 Manson, 2 MacGregor, 3 
Koniger, 4 Roux, and others. 5 It is a malady due to the presence of a 
vegetable parasite and is found chiefly in the South Sea Islands and 
those of the Malay Archipelago. It has been recognized also in iso- 
lated cases both in India and China. 

Symptoms. — The disease is first declared, after artificial inocula- 
tion, by a period of delay ("incubation") lasting about nine days, 
after which minute reddish points appear, arranged for the most 
part in semicircles, the former rapidly developing into papules pro- 
ducing an intolerable pruritus. The growth thenceforward is re- 
ported to be at the rate of from five to ten millimetres each week. 
In a brief time lamella? of epidermis are detached, their free border 
being directed to the centre of the circular disk, the patch or patches 
when fully developed being represented by concentric rings, about 
five millimetres apart, suggesting a resemblance to " watered silk." 
The scales may be as large square as half a centimetre, with curling 
edges which later become horny and much darker in color. It is 
said that the hand passed over such patches from the circumference 
to the centre recognizes a smoothness of the surface, but when the 
motion is reversed, from centre to periphery, the scales are raised 
and resist the fingers. The appearance of the older patches suggests 
a skin covered with clay. The process of production of the concentric 
rings is reported to be, first, by the elevation of a central point of the 
epidermis and the formation there by the fungus of a brownish mass ; 
then by separation of the epidermis at the central point, with persist- 
ence for a time of attachments at the border ; then by liberation of the 
attached edge by friction or otherwise ; and finally by exposure of the 
corium. Just beyond this line a brownish rim declares the line of ad- 
vance of the fungus beneath the epidermis. When the ring thus 
formed has attained a diameter of about five millimetres, a brown 
point again appears centrally, and there is a repetition of the process 
originally observed in the primary ring. 

All portions of the body and large areas of the general surface 
may be affected ; but the scalp, face, palms and soles, axilla?, and 
nails seem usually to be spared ; when the hairy parts (scalp, pubes, 
axilla?) are involved, the disease spares the follicles, and its manage- 
ment is thus declared to be correspondingly facile. Though the 
hairs themselves are not invaded, they are said to fall when the dis- 
ease extends over the hairy regions of the body. When the disease 
spontaneously disappears from any portion of the integument there 
are left persistent, deep-colored rings or circles where the scaling 
originally occurred. 

The itching is commonly intense; the scales at times (and in 

1 Glasgow Med. Jour., 1870, p. 502. 

2 Tropical Diseases, p. 628; China Imp. Merit. Cut. Med. Kep., 1879, xvi., p. 1; 
Med. Times and Gazette, 1879, ii.. p. 342. 

3 Glasgow Med. Jour.. 1876, p. 343. 
4 Virehow's Arehiv, 1878, lxxii., p. 413. 

5 For bibliography, see Scheube, Diseases of Warm Countries, p. 526. 



TINEA IMBRICATA. 1039 

places relatively inaccessible to the hands in scratching, such as over 
the interscapular region) may be half an inch in diameter and from 
one-eighth to half an inch apart. When bulky and corneous, they 
give to the body the aspect of being clay-coated. The patches may 
extend at the rate of from one-quarter to a half an inch each week. 
A somewhat characteristic " piebald " appearance is produced in 
places where the scales have been removed and the resulting pigmen- 
tation is partial. The scaling is most marked in parts contiguous to 
healthy skin. The disorder is exceedingly chronic in career, but is 
modified, especially in its pruritic symptoms, when occurring in 
milder climates. 

Etiology. — Tinea imbricata is a contagious disorder affecting per- 
sons of both sexes and all ages, and is produced by a vegetable para- 
site. The disease in certain localities is endemic. It has been pro- 
duced by experimental transmission from a diseased to a healthy skin. 

Pathology. — The fungus recognized in microscopic examination of 
the scales from a morbid patch after moistening with liquor potassas, 
resembles that of the trichophyton. Saboraud and Nieuwenhuis 
believe it to be a variety of the large-spored trichophyton. Tribon- 
deau reports that it is not a trichophyton, but an aspergillus, termed 
by him lepidopliyton. The growth of the organism is in the lower 
epidermis, sparing, however, the hair-pouches. The mycelium is 
thick and interlaced, compounded of short, rounded segments which 
branch dichotomously. It has been cultivated on nutrient media. 
The spores are oval, pigmented in dark-reddish hues, and irregularly 
contoured. The proportion of spores to mycelium differs in different 
observations probably as a result of the different age of the specimens 
under examination. As the fungus does not perish in the regions 
invaded, it burrows rapidly beneath the newly formed epidermis as 
soon as the latter is formed. In this way Manson explains the fea- 
tures of concentric scaling and the persistence of the disease. 

Diagnosis. — The diagnosis from " Giant Ringworm," " Boatman's 
Ringworm," Dhobie Itch, "Majee's Dad"- — forms of trichophyton 
as it occurs in luxuriant vegetation upon the smooth portions of the 
body in tropical countries — is made readily. In these forms of ring- 
worm the central area clears, while in tinea imbricata the central part 
of the patch is made up of concentric rings. The recognition of the 
parasite is essential. 

Treatment. — The scales are removed readily with soap and water 
or by alkaline baths, and chrysarobin, pyrogallol, or iodine ointment 
(Manson advocates strong linimentum iodi) is well rubbed into the 
part. In some cases strong lotions are employed of the same chemical 
constitution. The clothing of the patient should be boiled if not de- 
stroyed by burning. 

Prognosis. — The prognosis is favorable. 

Pinta. — Sp., Pintar, to paint. Mai de los Pintos, Mai Pintado, 
Pinto, Cute, Cativi, Tinna, Quirica, Spotted Sickness, Spotted Dis- 



1040 DISEASES OF TEE TEOPICS. 

ease of Central America, Pontius Carateus. Fr., Carathe.) Pinta 
is an endemic contagions dermatomycosis, characterized by the 
development of pigmented patches upon the skin in different colors, 
unconnected with the general health of the patient and affecting sub- 
jects of both sexes and all ages. 

The disease occurs in tropical America, especially in Mexico, Cen- 
tral America, Venezuela, Colombia, Bolivia, Chili, Peru, and Brazil ; 
but it has been found also in Xorth Africa, and, it is believed, also in 
Guiana. 1 

Symptoms. — Pinta begins at one or several points of the body- 
surface, whence it is distributed more or less generally by auto-infec- 
tion. The disease by some authors is said to be preceded by prodro- 
mata of chills, fever, anorexia, cephalalgia, diarrhoea, and emesis, 
lasting for one week, the cutaneous symptoms developing about 
one month later. The occurrence of such a prodromal stage has, 
however, been denied. 

The eruptive symptoms develop gradually. The hands, face, and 
other exposed parts usually are involved first. Large areas subse- 
quently are formed by increase in the dimensions, and also by coales- 
cence of original macules, the spread of the disease being asymmetri- 
cal and peripheral. The spots may be characteristically yellowish, 
reddish, bluish, blackish, whitish, or gray, the hue at first being mono- 
chromatic; later, as the disease spreads, the different colors named 
above may be exhibited side by side. The patches are well defined, 
and do not affect the palms and soles. On the scalp the hairs whiten 
and fall. 

The surface of the body, when extensively involved, presents an 
odd-looking, piebald appearance, due in part to epiphytic changes and 
in part to the development of vitiliginous patches in the skin. Itch- 
ing is produced in various degrees, according to the extent and sever- 
ity of the disorder. When the affection has lasted for some time, a 
disgusting odor is exhaled, and the surface exfoliates, an early fur- 
furaceous desquamation being replaced later by scaling in large flake-. 

Two types are described: one superficial, represented by blackish 
and bluish patches ; and a deeper form, said to be more obstinate, with 
reddish and whitish patches, in which the deeper portions of the epi- 
dermis are involved. 

Though displayed for the most part asymmetrically, the patches 
may cover the entire surface of the body, and even invade the mucous 
membranes of the alimentary tract. When confluence occurs, large 
areas of the skin may be involved, displaying then the usual features 
of hyperkeratinization. with pityriasie, occasionally larger and coarser, 
scales, infiltration, occasional Assuring, and complete or partial color- 
change and loss of hair. In final evolution the symptoms are highly 
suggestive of other dermatoses, such as trichophytosis, favus, some of 

bibliography: Edgar from Jour. Trop. Med., p. 531. Manson. Tropical Dis- 
eases, p. 776. Gomez, Du Carathes ou tache endemique des Cordilleres, Paris. 
1879. Hirsch, Handbueh histo.-geopr. Pathologie, 1883, 2d ed., ii.. p. 263. Mon- 
toya and Florez. Annales, 1897. s. iii.. viii.. p. 464. 



PINT A. 1041 

the forms of lupus, aud erythematous eczema. There may be ulcer- 
ative complications. 

Etiology. — Pinta is a contagious disease, affecting persons of both 
sexes and all ages save infants ; but is much more common among 
the filthy and the neglected than in others. It is produced by the 
growth of a cryptogamous fungus in the superficial portions of the 
skin. 

Pathology. — Scales scraped from the skin moistened with liquor 
potassse and placed under a microscope, exhibit round or oval, blackish 
spores 8-12 ^ in diameter; and highly refracting, short, dichotomous 
filaments of mycelium are distinguishable. The effective parasite 
recognized by Montoya y Florez (cited by Manson) are fungi, chiefly 
Penicillium, Aspergillus, and Monilia. Fine filaments furnish hyphse 
which terminate in clubs surrounding chaplets of spores. Sterigmata 
encircle the sporulating elements. The fungi are found chiefly in the 
superficial layers of the epiderm, but may also, in advanced cases, be 
recognized in the rete. Whether the differences in color be due to 
variations in the fungi, or to pigmentation of the spores and filaments, 
is not determined. 

Diagnosis. — The patches of chloasma, vitiligo, and lepra are dis- 
tinguished readily from those of pinta by considering that, in the two 
diseases first named, there are no surface-changes in the horny layer 
of the epidermis, and in the second the existence of a systemic affec- 
tion is established readily. The absence of anaesthesia in the patches 
of pinta, the discovery of microsporon furfur in tinea versicolor, and 
of microsporon minutissimum in erythrasma, and the special charac- 
ters of the psoriasiform dermatoses, are all of significance. Care 
should be taken to exclude the symptoms of the prefungoid stage of 
mycosis fungoides. 

Treatment. — Chrysarobin, sulphur, iodine, naphtol, and, if needed, 
corrosive sublimate lotions have been found useful. Cleanliness and 
strict observance of the requirements of hygiene are demanded espe- 
cially in the class of patients who are affected most often by the dis- 
ease. 

Prognosis.- — The disease may persist indefinitely if not relieved. 
It yields to proper parasiticidal treatment. Mild relapses occur. 
The general health is not involved. 

Piedra. 1 — (Sp., piedra, a stone. Fr., Tricliomycose Nodulaire.) 
Piedra is a name given to a disorder affecting chiefly the natives 
of certain districts in Colombia, South America. Both men and 
women, more frequently the latter, and persons of all races are 
liable to contract the disease, which involves the shaft of the hairs of 
the scalp chiefly, but also the head and other hairy regions. The in- 

1 Manson, 1. c, p. 780. Morris, London Pathological Society's Transactions, 
1879, p. 441 (with plate), and Medical Times and Gazette, 1879. Juhel Kenoy, 
Annales, 1888, s. ii., ix., p. 77, and 1890, s. iii., i., p. 766 (with illustrations). 
Trachsler, Monatshefte, 1896, xxii., p. 1. 

66 



1042 DISEASES OF THE TEOPICS. 

dividual filaments are dotted at irregularly disposed points with 
minute nodosities, apparently as hard as stone, from which circum- 
stance the disease has acquired its Spanish name. The nodes are pin- 
head-sized and gritty, so small at times as to be scarcely perceptible 
to the eye, though distinctly recognized on palpation. A score or 
more have been found on a single hair sixty centimetres in length. 
The affected filaments are distorted, and apt to be matted and twisted, 
as in plica. Each node is fastened to the hair like a sheath, though 
it may be implanted on one side only ; is divided readily with a sharp 
knife ; and is colored in various shades of gray, brown, or black. 
When a comb is passed through the hairs a distinct crepitation is pro- 
duced by friction against the dense, nit-like nodes. 

The disease has been observed in a few instances in Europe, and 
once by ourselves in the case of a young girl in whom the eyelashes of 
both lids on each side were dotted with numerous jet-black, horny, 
and dense spherical masses, firmly attached to the filaments. 

Etiology and Pathology. — According to Juhel-Eenoy, the nodes are 
composed of numerous spore-like bodies, recognized readily by soak- 
ing the hairs in dilute liquor potassse after washing in ether. The 
spores are twice the size of those furnished by the trichophytons, are 
polyhedral as a result of counterpressure, and form a species of tessel- 
lated mosaic, the elements of which are united by a greenish soluble 
cement, in which are incorporated minute rods resembling bacteria. 

Other views advanced are that the disease is allied more or less to 
Beigel and Fox's " chignon fungus," that several varieties of fungus 
may be responsible for the concretions, and that the origin of the node- 
like masses is due primarily to a species of mucilaginous oil em- 
ployed by the natives of Colombia for hair-dressing. 

Diagnosis. — The disease is not to be confounded with trichorrhexis 
nodosa (though Scheube distinctly affirms that the two are identical), 
an affection in which the hair-shaft is involved; nor with lepothrix 
(trichomycosis nodosa), occasionally recognized on the hairs of the 
axillary and pubic regions; nor yet with monilethrix (q. v.), a still 
rarer affection of the hairs of the scalp. 

Treatment. — The disease is relieved readily by soap and water 
ablutions and by the employment of parasiticides. 

Phagedena Tropica. — (Tropiccrt Sloughing Phagedena, Ulcer of 
Yemen, Aden Ulcer, Cochin China Ulcer, Mozambique Ulcer. Fr., 
Ulcere phagedenique des Pays Chauds, Ulcere endemique, Pha- 
gedenisme des Pays Chauds, Sarnies or Sarnes; Ger., Tropische Pha- 
gedanismus.) Phagedenic ulceration, varying in type and severity, 
has been observed in almost all of the tropical countries of Europe, 
Asia, Africa, and America. While it is not certain that the several 
disorders to which the name has been given in different parts of the 
world designate the same morbid state, it is clear that manv condi- 



PHAGEDENA TROPICA. 1043 

tions to which the name has been applied are identical in their nature 
and possibly those recognized in hospital gangrene. 1 

Symptoms. — The onset of the disease is commonly at some point 
of the body-surface which has been the site of a traumatism slight or 
severe in grade (excoriations, contusions, insect-bites ; or the point 
where there has been a localized dermatitis from any cause — e. g., 
syphilis, pus-infection, eczema, etc.). There may be a predisposition 
to the affection in consequence of a previous state of depressed health. 
The disease may begin with a single or with multiple lesions, which 
usually develop over the dorsum of the foot or over the anterior face 
of the leg. 

The first lesions are vesicular or bullous in character, the bursting 
of which releases a serous or sero-purulent fluid. Ulceration prompt- 
ly follows with the formation of a necrotic floor made up of indolent 
granulations, and grayish, pseudomembranous or pultaceous, partly 
adherent sloughs. The edges are undermined, the odor exhaled from 
the sore putrescent, and the extension of the disease from centre to 
both surrounding skin and subcutaneous tissue exceedingly rapid. 
In the progress of the sore, muscles, tendons, aponeuroses, periosteum, 
and, in cases, even bone, joints, and the larger bloodvessels may be 
attacked. 

The affected part is exquisitely painful and tender ; the surround- 
ing tissues often cedematous and actively congested ; the general con- 
dition of the sufferer one of extreme adynamia, which may be accom- 
panied by chills, fever, and the signs of a dangerous septicemia. 

Etiology. — The disease is unquestionably more prevalent in those 
residents of the tropics who have been debilitated by malaria, exces- 
sive heat, and moisture of the climate, malnutrition from whatever 
cause, and similar agencies. Natives as a rule suffer more than visi- 
tors from temperate zones. Beggars, men chiefly engaged in severe 
toil, those exposed in hot and rainy seasons, the uncleanly, and those 
wretchedly housed, furnish the larger number of all patients. 

Pathology. — No single specific organism has yet been demonstrated 
to be efficient in the production of the disease. An aerobic (Boinet) 
and also an anerobic (Matzerhauer) bacillus have been believed to be 
responsible for the disease. Le Dantec recognized bacilli 7 to 12 /*, 
in length, and immobile. Those seen by Blaise were longer and bent ; 
those by Crendiropoulo were capable of destroying rabbits and pi- 
geons, the cultures giving off a putrid odor. The rods were two or 
three times as long as they were broad, with rounded extremities. 
Sufficiently reduced they produced phagedenic sores in the lower 
animals. 

1 Seheube, Falcke, Cantlie, loc. cit., p. 544; Manson, loc. eit., p. 751; Blaise, 
Gaz. hebd. de Med. et de Chir., Oct. 10, 1897; J. Brault, Annales, 1897, s. iii., viii., 
p. 165; Boinet, ibid., 1890, s. iii., i., pp. 210 and 307; Crendiropoulo, Ann. de FInst. 
Past., 1897, 3d., p. 784; Le Dantec, Arch, de Med. Nav., 1885, p. 448, and 1899, 
lxxi., p. 133; O. Dempwolf, Arch. f. Schiffs u. Trop. Hyg., 1898, ii., p. 282; 
Legrain et Fradet, Annales, 1897, s. iii., viii., p. 781; Kasch, Ch., Allg. med. Ctr.- 
Ztg., 1896, lxv., p. 951. 



1044 DISEASES OF TEE TROPICS. 

Treatment. — The treatment of tropical sloughing phagedena is, 
first, by support of the general health in accordance with the methods 
universally accepted in science; by thorough erasion, cauterization, 
and aseptic dressings. 

Stoker has employed oxygen and air locally. Where it is practi- 
cable, the best local treatment is continuous immersion of the part in 
water of a temperature as high as is grateful, medicated with boric 
acid. 

As the disease is infective, patients should be isolated. 

Prognosis. — When repair ensues, the improvement in the local 
condition of the sore is by the usual course of granulation, casting 
off of sloughs, and cicatrization. Mutilations, deformities, anchy- 
loses, contractures, and relapses with fever are not rare. A fatal 
result may occur from any of the common complications of such 
a state (intercurrent diarrhoea, pneumonia, hemorrhage, etc.). 



INFECTIOUS GRANULOMATA OF TROPICAL AND WARM 
COUNTRIES. 

LEPRA.* 
(Gr., Xeirpbc, scaly.) 

(Leprosy, Satyriasis, Elephantiasis Gr.ecorum, Leontiasis, 
Lepra Arabum. Fr., Lepee, Ladrerie; Ger., Aussatz; Ital., 
Lebbra; Norweg., Spedalskhed.) 

Leprosy to-day is recognized in almost all of the countries of the 
earth, and groups of victims of the malady, even in considerable num- 
ber, are found in lands both within and even far to the north of the 
temperate zone. The disease, none the less, is properly considered 
with those of tropical and warm countries, for the reason that in these 
latter are the largest number of affected individuals, and those exhibit- 

1 The literature of lepra is voluminous. The references appended include a few 
of the classical and some of the more recent contributions to the subject. Daniels- 
sen and Boeck, Traite de la Spedalskhed, etc., with atlas, Paris, 1848; A. Hansen, 
Archiv, 1871, Cong, med., de sc. med. de Copenhagen, 1884. Van Dyke Carter, 
Leprosy, etc., 1874. Hansen and Looft (trans, by Walker), London, 1895. Leloir, 
Traite de Lepre (planches), Paris, 1886. Unna, Zambaco, Leprosy and Syphilis, 
Int. Cong, of Derm., London, 1896. Lepra-Conferenz, Berlin, Oct., 1897 (three vol- 
umes; full bibliography). Santon, La Leprose, Paris, 1901 (plates). Victor 
Babes, Die Lepra, Wien, 1901 (68 illustrations, 8 colored plates, and bibliography 
to date). Campana, Lepra, 3d ed., 1907. 

Among American contributors may be named: Barnes, Arch, of Med., Dec, 
1881, vi., p. 201; Bemiss, New Orleans Med. and Surg. Jour., 1880, n. s., vii., 
p. 923; Jones, ibid., March, 1878; Dyer, Phila. Med. Jour., 1898, ii., p. 567; Solo- 
men, Trans. Louisiana State Medical Association, 1879; Morrow, Twentieth Cen- 
tury Practice, vol. xv., p. 403, and J. C. D., 1889, p. 147 ; Bracken, Minnesota 
State Board of Health, 1901, and Phila. Med. Jour., 1898, ii., p. 1309; McDonald, 
T. Jonathan, J. A. M. A., 1903, xl., p. 1567 (examination of 150 cases in Hawaii) ; 
Douglass W. Montgomery, Med. Eecord, 1902 (spontaneous cure in a leper family), 
and J. A. M. A.. 1894, xxiii., p. 136; Hyde, Transactions Congress of American 
Physicians and Surgeons, 1894, iii., p. 103 (with bibliography) ; J. C. White, 
Transactions International Leprosy Convention, 1897, vol. i. 



LEPRA. 



1045 



ing the severest types of the disorder and its most dangerous ravages. 
Leprosy is believed to have originated in the Orient and to be as 
old as the records of history. Together with a group of dermatoses, 
probably of a different nature, it is represented without question in 
the " Zaarath " of the Hebrew Scriptures. Once prominent in the 
list of the scourges of the old world, its prevalence to-day is restricted 
in the lands where it still occurs ; and it is the rarest of maladies in 
countries like Great Britain, where it once existed. It is found now 
in Norway, and to a less extent in Sweden ; in Bulgaria, Greece, 
Bussia, Austro-Hungary, and Italy, with a much reduced percentage 
in middle Europe ; in India, Java, and China ; in Egypt, Algiers, and 

Fig. 211. 




Leprosy. (Howard Morrow.) 



Southern Africa; in Australia; and in both North and South, in- 
cluding particularly Central America, Cuba, and the Antilles. In 
the United States it has been recognized chiefly in New Orleans, San 
Erancisco (predominantly among the Chinese population of that city) , 
and in portions of Minnesota, Wisconsin, and Iowa. Isolated cases 
have been recognized in almost every State of the Union. Leprous 
patients are presented not rarely at our clinic in Chicago ; as also at 
the public charities of New York, Philadelphia, Boston, and other 
centres of population. It has been estimated that the number of 



1046 DISEASES OF THE TBOPICS. 

lepers in the United States varies between two hundred and five hun- 
dred. The disease is represented also in what is reported as a dimin- 
ishing frequency in the dependencies of the United States, the Ha- 
waiian Islands, Porto Kico, and the Philippines. 

Symptoms. — In whatever form leprosy may ultimately be mani- 
fested its appearance is preceded usually by the prodromic symptoms 

Fig. 212. 




Leproma of ocular globe. Epithelial horn pointing upward from eye. 
(Howard Mobbow.) 

generally recognized as precursors of severe constitutional disease. 
These symptoms are : anorexia ; cephalalgia ; chills, alternating with 
mild or with severe febrile attacks ; depression ; epistaxis ; gastrointes- 
tinal disturbances ; and insomnia. Their duration is exceedingly var- 
iable; in some cases patients will remember that these or similar 
symptoms preceded for years the earliest outbreak of lepra. In other 
cases but a few weeks' interval occurs between the prodromic and the 
successive stages of the disease. The character of the prodromata fur- 
nishes no clue to the severity and type of the oncoming disorder. The 
earlier cutaneous lesions of leprosy are tubercular, macular, or bul- 
lous. They may be coincident or successive, or one or two of these 
types may so far predominate that another either may be wanting 
altogether or may possess in the general pathological history but a 
trifling significance. It has thus been customary to make an entirely 
artificial distinction between cases of leprosy by assigning them to 



1047 



three varieties — tubercular, macular, and anaesthetic. It will be un- 
derstood, then, in separately considering these three forms, that the 
distinction between them is useful simply for purposes of clinical 
classification ; that mixed cases of the disease occur which it would be 
difficult to assign to either variety exclusively; and that each case 
merely represents a predominance of certain lesions at one patholog- 
ical epoch. It should be noted also that the symptoms of leprosy are 
remarkable for their polymorphism, a wide variation often existing 
between the character of two or more lesions which at any given 
moment are apparent. This variation is owing largely to the fact 



Fig. 213. 




(Howard Morrow.) 



that leprosy is a general and constitutional disorder, the cutaneous 
symptoms of which are simply its surface-markings. 

Lepra Tuberosa {Tuberculated, Nodulated, or Tegumentary Lep- 
rosy). — From 10 to 50 per cent, of cases are of the nodular type, the 
larger proportions apparently holding good for colder climates. After 
the occurrence of chills and a febrile movement of remittent, inter- 
mittent, or continuous type, lasting for weeks or months, macular 



1048 DISEASES OF THE TEOPICS. 

lesions appear, which are bean- to tomato-sized, reddish, brownish, or 
bronze-hued patches, roundish, oval, or irregular in contour, well de- 
fined and occurring upon the face, trunk, or extremities. The skin 
covering these lesions is either smooth and shining, as if oiled, or is 
infiltrated moderately and elevated. The surface of the erythema- 
tous spots is often hypersesthetic. After a period ranging in dura- 
tion from weeks to years, tubercles (lepromata) rise from the macu- 
lations varying in size from that of a pea to that of a nut, though they 
may be as large as a tomato. They are yellowish, reddish brown, or 
bronzed in color, often shining as if varnished or oiled, are covered 
with a soft, natural, or slightly desquamating epidermis, roundish or 
irregular in contour, and are either isolated or grouped. Numbers 
of very small and ill-determined nodules may often be recognized by 
careful examination of the skin in the vicinity of those fully devel- 
oped. They may fuse and produce broad infiltrations, from the sur- 
face of which spring new nodules. They may be either cutaneous 
or subcutaneous in situation, and be softish or firm to the touch. The 
eruption of these tubercles is usually at the outset preceded by fever, 
as well as by oedema of the region involved — eyelids, ears, etc. The 
lesions are often in varying grades anaesthetic. 

The site of predilection of leprous tubercles is the face, and their 
massing in great numbers upon this region produces the characteristic 
deformity of the countenance that has given to the disease one of its 
names, leontiasis (face of a lion). In such faces the tubercles are 
ranged in parallel series above the brows, down the nose, over the 
cheeks, the lips, and the chin. Tn consequence of the infiltration 
and development of the lesions the brows deeply overhang the globes 
of the eyes, the eyelids become affected with partial ptosis, the lips 
pout, and the ears are so studded with tubercular masses as to project 
from the side of the head. The trunk and extremities, including the 
palmar and plantar surfaces, are then usually to a less degree in- 
volved. Other parts which may be invaded are the axilla?, genital 
and mammary regions, and more rarely the neck and the palms and 
soles. Occasionally, indeed, with extensive development of tubercles 
upon the face and ears, there may not be more than from five to fifty 
tubercles upon the rest of the body, and these either widely dispersed 
and isolated or agglomerated in a single, hard, flat, elevated plaque of 
infiltration upon the elbow or the thigh. When confluence of tuber- 
cles occurs, large plaques of infiltration may form (lepromes en 
nappe), which are elevated and brownish or blackish in shade (mor- 
phcea nigra). In yet other cases the condition described by Bazin 
as leprous scleroderma occurs, in which dense infiltrations extend 
to both the derm and the hypoderm. The surface of these lesions is 
roughened, often desquamating, rarely ulcerated. 

With these cutaneous lesions there is often involvement of the 
mucous surfaces, especially the velum palati and the larynx. In the 
case of the lepers affected with the tubercular form of this disease, 



LEPRA. 1049 

who were exhibited at our clinic in 1879 and 1904, 1 there were 
marked gruffness and hoarseness of the voice, and the tongue, the 
larynx, and velum were studded with pinhead- to pea-sized, ashen- 
hued tubercles. Others may form upon the conjunctiva and the 
Schneiderian membrane, the gums, the inside of the cheeks, the 
tongue, the palate, the fauces, and the pharynx. 

These tubercles may degenerate into irregularly outlined, sharply 
cut, glazed ulcers, with a hemorrhagic or sloughing floor, or they may 
undergo resorption and disappear, leaving pigmented atrophic depres- 
sions, or they lose their shape in consequence of partial resorption. 
A large plaque may flatten centrally until an annular disk is left to 
indicate its former site. 

Among the coincident symptoms of the tubercular exanthem in 
lepra may be named : disturbance in the functions of sweat and seba- 
ceous secretion, thinning and loss of the hair in the regions impli- 
cated (especially of the eyebrows), and disorders of sensibility. 
Later results are to be noted in a nasal catarrh from implication of 
the Schneiderian membrane ; atrophy of the sexual organs in both 
sexes with impairment or total loss of procreative power, and reme- 
diless blindness, which may result from keratitis, iridocyclitis, or 
panophthalmia. 

It should be borne in mind, however, that the course of the dis- 
ease is exceedingly slow, and that years may elapse before these sev- 
eral changes are accomplished. The malady, indeed, often appears 
to be quiescent for months at a time, after which, with the occur- 
rence of fever, acute or subacute manifestations appear, including 
adenopathy, orchitis, slow or relatively rapid ulcerative processes, 
followed by gangrene ; and a relatively rapid progress may be made 
toward a fatal conclusion. Long before the latter is reached there 
are usually, in tubercular leprosy, intermingled symptoms of an- 
aesthetic type, such as the occurrence of bullae or of anaesthetic 
patches with and without pigmentation. Toward the last the mutila- 
tions effected by the disease may result (Lepra Mutilans). Pha- 
langes of the fingers or toes, whole digits, an entire hand or foot may 
then become wholly or partially detached by ulcerative, atrophic, or 
other degeneration of skin, bones, and ligaments, hastened or not by 
intercurrent attacks of lymphangitis, erysipelas, septicaemia, and irri- 
tative fever. 

The stadium of this type of the disease may extend through ten or 
more years. After its full development the dejected countenance of 
the leper, with his leonine facies and general appearance of cachexia 
is highly characteristic. 

Lepra Maculosa (Maculo-ancesthetic Lepra, Erythema Leprosum, 
Leprous Roseola). — This form of the disease is more common in 
tropical than in cold countries and is distinguished chiefly, as its 
name implies, by its macular lesions. These lesions have the general 

1 Chicago Med. Jour, and Exam., 1879, xxxix., p. 561, with cut showing ap- 
pearance of larynx. 



1050 DISEASES OF THE TROPICS. 

character of those described as preceding the appearance of the lep- 
rous tubercles. In size they vary from that of a small coin to areas 
as large as a platter. They are diffused or circumscribed, roundish 
or irregularly shaped, and in color yellowish, brownish, or bronzed, 
often shining or glazed. They may be infiltrated, and may be raised 
slightly from, or on a level with, the adjacent tissues. At times they 
appear as lardaceous deposits in the skin, whitish, reddish, or even 
blackish in color, with a telangiectasic border. These patches are 
usually at first hyperaesthetic, but finally they become insensitive, 
so that a lancet can be thrust deeply into them without producing 
the slightest sensation. 

The pigment-variations in macular lepra are noticeable. At 
times a distinctly anaesthetic patch may readily be limited by its lack 
of sensation and of normal color ; at other times either symptom may 
fail to correspond with the area of involvement defined by the other. 
Thus, a palm- to platter-sized, texturally unaltered area over the thigh 
or the belly may suggest a vitiligo by its relatively slight pigmenta- 
tion and its distinct contour, beyond which are sepia to deep choco- 
late tints, gradually fading toward some adjacent and similarly in- 
volved patch. Yet this area will often differ materially from that of 
vitiligo in other respects. 

Every point of the former may be totally insensitive to the prick 
of the lancet, and, moreover, be of a dull, tawny, yellowish, or parch- 
ment-like hue, never having the peculiar milky -white tinge of vitiligo. 
Again, this anaesthesia may extend widely beyond the line traced by 
the pigment-anomaly, or even within the latter may vary, islets of skin 
capable of perceiving sensations being in cases here and there discern- 
ible. The regions chiefly affected are: the back, the exposed parts, 
the backs of the hands and wrists, the forehead, cheeks, ears, dorsum 
of feet, and ankles. The eruption may be scanty or general ; conspic- 
uous, or so insignificant as to escape attention save when closely scru- 
tinized. A few bullae may be intermingled with the macules, the 
skin otherwise being texturally unaltered. The eruptive symptoms 
are associated commonly, early or late, with the graver phenomena 
described below. 

Lepra Anassthetica (Lepra Trophonewotica, Nerve-leprosy, Atro- 
phic Leprosy). — There may be one or two years of ill-health preced- 
ing the development of this form of lepra, the patient suffering from 
chills and vague sensations of malaise. Usually at this time the skin 
becomes hyperaesthetic in localized patches, sometimes generally ; and 
special nerves in consequence of their enlargement become accessible 
to the touch. Those especially named below become tender and the 
seat of lancinating or shooting pains. This clinical variety, as has 
been described, may be commingled in its symptoms with each of the 
other types. With and without such commingling, however, there 
commonly is noted after exposure to cold, or after being subject to 
chills first an eruption of erythematous patches or of bullae, bean- to 
large-nut-sized, with a roof-wall constituted of the entire thickness 



LEPRA. 



1051 



of the epidermis, filled with a clear-tinted or blood-mixed serum, oc- 
curring usually upon the extremities. The cicatrices which follow 
these bullae are atrophic patches, each often far greater in extent than 
the base of the original bleb, whitish, shining, glazed, or better de- 
scribed as of a tint suggesting the hue of mica; circular in outline, 
forming also the dumb-bell figure by coalescence or juxtaposition. 
These cicatrices are always anaesthetic, and they may coexist with 
macular and anaesthetic patches upon the trunk or other portions of 
the body : face, hands, feet, ankles, thighs — rarely the palms and soles. 
Neither those of the one class nor of the other, however, are disposed 

Fig. 214. 




Anaesthetic leprosy with mutilating results. (From a photograph of a leper in the 
Sandwich Islands.) 



over the surface of the body in lines, bands, or curves corresponding 
with the distribution of the cutaneous nerves. Asymmetry is the 
rule. Occasionally, however, the ulnar and other nerves (median, 
posterior tibial, peroneal, facial, and radial) accessible to the touch 
are tumid, tender, insensitive, or as rigid as indurated cords; fusi- 



1052 DISEASES OF THE TBOPICS. 

form, reddish-gray swellings may be recognized with the naked eye 
along the nerve-tract, of translucent and gelatinous aspect. General 
atrophic cutaneous symptoms follow : the skin becomes dry and harsh ; 
there is manifestly little or no sebaceous product ; the sweat is scanty ; 
the muscles atrophy; the hairs fall; the lymphatic ganglia enlarge; 
the skin of the face seems tightly stretched over the bones. As a 
result of deforming atrophy of the eyelids epiphora and consequent 
orbicular changes ensue and the parted lips permit constant escape 
of saliva. The fingers are half -drawn into the palm of the hand; 
the nails are distorted, and, later, ulceration occurs (Fig. 214). 

The ulcers are irregular, oval, roundish, linear; covered with 
thin, blackish, flattened, tenacious, rarely rupioid, crusts ; their bases 
are soft ; their floors covered with a pultaceous debris often mixed 
with blood ; the whole usually insensitive to every foreign body and 
external application. Lastly, the symptoms of lepra mutilans may 
occur, digits, or portions of the carpus, metacarpus, or corresponding 
parts of the foot, being detached from the body. 

Death may ensue, at any time during the course of the disease, 
from septicaemia, exhaustion, or any of the intercurrent affections to 
which a patient in such a condition is particularly disposed. Thus, 
a leper was accidentally choked to death in San Francisco by some 
perversion of the function of deglutition. The disease, however, in 
the anaesthetic form is said to last from eighteen to twenty years, 
and is thus less rapidly fatal than the tubercular variety. 

Considering the several clinical varieties of leprosy named above, 
and the mixed forms resulting from a commingling in some cases of 
the features of all varieties, the result is merely an analysis of the 
symptoms in an enormous clinical field. There are not, in fact, any 
forms or varieties of this disorder ; there is but one disease, which ex- 
hibits itself in widely differing manifestations, and these at one time 
and in one country assume a predominant phase, while with a different 
environment and in another race other phenomena appear. Thus, 
lepra tuberosa is reported in from 50 to 75 per cent, of patients 
affected with the disease in the north of Europe, and in from 10 to 
20 per cent, of those in tropical countries; while anaesthetic lepra 
in the geographical limits last named, is represented by two-thirds 
of patients, and in the northern latitudes by less than one-third. 
" Mixed forms " are less often reported than others, but as a matter 
of fact are the more often observed. The reason for this apparent 
discrepancy lies in the fact that really pure eases of any form are rare. 
It is best to look upon the expressions of lepra as it is accepted to 
regard the phenomena of syphilis: in each there is a single morbid 
principle ; there are in both no true varieties ; and the external symp- 
toms differ chiefly because of special accidents of environment, of 
race, or of individual peculiarities. 

Looking at the variant symptoms of lepra, a wide range occurs 
in all stages. In the evolution of the disease there is a usual order of 
fever, eruptive symptoms, and ulcerative or destructive sequels. In 



LEPRA. 1053 

the prodromic period there are often chilliness, profuse diaphoresis, 
insomnia, inappetence, diarrhoea, vertigo, and even a bullous efflores- 
cence upon the surface. These prodromata are rarely wanting, and, 
after lasting for weeks, months, or years, are followed by sensations 
of chilliness, with remitting or intermitting febrile symptoms, the 
temperature rising from 100° to 105° F. The tongue becomes of a 
reddish hue, the listlessness and sluggishness continue, and the typical 
cutaneous lesions of the disease (leprous spots) appear, commonly 
on some portions of the face, with or without oedema. In some cases 
the prodromic symptoms and fever and chilliness are either absent or, 
what is more probable, are unnoticed, and then the disease may be 
first recognized by pains of a lancinating character, tenderness, and 
aching, especially along the course of the ulnar, peroneal, median, 
saphenous, or other nerves ; or the result may be hyperesthesia, anaes- 
thesia, or pricking, tingling, and similar sensations in regions sup- 
plied by special nerves. The greatest variation is observed in the 
length of time during which these early symptoms, with more or less 
vagueness of expression, exist. Later, tubercles, nodules, bullae, mac- 
ules, hyperaesthetic and anaesthetic patches appear with gradual -devel- 
opment of other and non-cutaneous symptoms, paralysis, exaggerated 
tendon-reflexes, and atheromatous papules upon the palpebral mem- 
branes and cornea. At times there results an ulcerative keratitis. 
In every large leper-hospital the number of inmates, both men and 
women, who have become totally blind in consequence of the ravages 
of the disease, is considerable. In many, too, nodules appear over the 
chest, genital regions, and extremities, as well as upon the mucous 
surfaces of the mouth and respiratory tract. The voice becomes rau- 
cous, while recrudescences of the disease occur either along the one 
(tubercular) or the other (anaesthetic) line toward the final stages of 
degeneration and mutilation. 

The disease is seen in all typical forms, even in regions where 
leprosy is least prevalent. There may be a genuine leprous pachyder- 
mia with enormous increase in the volume of the hands and feet, ac- 
companied by severe onychia and paronychia, and deep ulcerations 
about the nails. In some cases tumefaction of an entire limb results, 
strongly resembling an elephantiasis. The nose may be stuffed with 
leprous tubercles ; and a large number of cutaneous symptoms of the 
most varying type develop in and upon the leprous skin as the result 
of secondary infection, of accidents, or of invasion by pus-cocci, etc., 
for it must be remembered that in most cases the leprous belong to the 
filthy and impoverished classes of society. Thus, there are often de- 
veloped eczemas, erythematous, achromic and hyperchromic spots 
and disks, annular lesions resembling those seen in syphilis, bullae rap- 
idly becoming gangrenous (eryiheme polymorphe lepreux bulleux et 
escliarotique, of Leloir), nodules of the usual size and hue of those in 
lepra (pinhead- to nut-sized, pigmented, reddish brown, copper tinted, 
glazed, shining as if oiled), and enormous infiltrations within and 
below the derma, even the production of large tumors of leprous tissue. 



1054 DISEASES OF THE TEOPICS. 

The generative apparatus may seriously be involved, the uterus, 
Fallopian tubes, and ovaries being the seat of leprous nodules or dif- 
fuse lepromatous infiltrations; as may be also the testicles, prostate 
gland, and penis. The breasts are also stuffed with tubercles; but 
they, as also the other organs named, may simply waste under the 
influence of the disease. Sexual power is retained longer than is com- 
monly believed. In the colored races the eruptive symptoms are 
tinted in yellowish and reddish shades, a result due to contrast with 
the hue of pigmented skins. 

Etiology. — Leprosy is a contagious and infectious parasitic disor- 
der produced by the bacillus leprae. This organism was discovered 
by Armauer Hansen in 1874, and is present in large numbers in 
tubercular forms of the disease, being relatively absent in amesthetic 
lepra. It strongly resembles the bacillus of tuberculosis. These ba- 
cilli have been found in the dwellings and clothing of lepers as well 
as in the dust of apartments occupied by victims of the disease. 

Secretions of a leprous patient containing bacilli or their spores 
are the usual vehicle by which the disease is transmitted. The ques- 
tion of the inheritance of leprosy may be regarded to-day as in much 
the same position as that relating to the inheritance of tuberculosis ; 
no foetus, no newborn living child has been known to exhibit the symp- 
toms of either disease. Tonkin, 1 in an analysis made by him of 220 
cases of leprosy observed in Sudan, states that the spread of the dis- 
ease is not even remotely affected by any such process. Babes, how- 
ever, cites several cases where infants but a few weeks old exhibited 
symptoms of leprosy. Men are affected with the disease more often 
than women. Infection is more common after the second decade, 
though children are occasionally among its victims. 

The geographical distribution of leprosy is widely extended. In 
countries where it has not previously existed its appearance is due in- 
variably to the infection of sound individuals by lepers first exhibiting 
symptoms where the disease is prevalent. Neisser formulates the 
law of its prevalence by stating that the number of lepers in any 
country bears an inverse ratio to the laws executed for the care and 
isolation of infected persons. 

With a wide geographical distribution, the disease exists endem- 
ically in certain countries, and also in certain regions of the same 
country, with greater frequency than in others. All attempts, how- 
ever, to connect its origin with malaria, with a residence near inun- 
dated sea-marshes, with the ingestion of a diet consisting largely of 
fish, or of a diet from which salt largely has been excluded, have 
failed of recognized success. The disease, however, seems to spread 
more rapidly in damp and cold, or warm and moist climates than in 
temperate countries. It is true that probably the larger number of 
all living lepers are those who have been poorly fed and otherwise 
subjected to the most insalubrious of influences, but the disease also 
attacks, though far more rarely, persons whose social position and 
1 Lancet, April 18, 1903. 




LEPRA. 1055 

hygienic surroundings are of the best. It occurs in both sexes — 
though more frequently in men — and at all ages; and, despite all 
effort to show the contrary, bears no relation to syphilis.- Lepers, 
however, become syphilitic if infected with that disease, precisely as 
they may and do acquire variola, varicella, morbilli, erysipelas, and 
phthisis. The Hebrew Scriptures are often interpreted as showing 
that the disease among the Jews in Pales- 
tine was regarded by them as contagious FlG - 215 - 
and so treated. The modern student of 
these writings will, however, be convinced 
that this interpretation is .erroneous. The 
leprosy of the book of Leviticus not only in- 
cludes lepra, as that term is understood to- 
day, but also psoriasis, scabies, and other 
cutaneous affections. The leper, in the eye 
of the Mosaic law, was ceremonially un- 
clean, and capable of communicating only a wl ^ rj g r ° £ %$S£S£. aff ^Au d 
ceremonial uncleanness. Several of the thor's case.) 
narratives contained in these books bear 

witness to the fact that the Oriental leper was occasionally seen doing 
service in the courts of kings and even in personal communication and 
contact with officers of high rank. 

Pathology. — The bacillus of leprosy is a delicate, rod-shaped, 
straight, or slightly curved parasite from one-half to three-fourths 
of the diameter of a red blood-corpuscle in length, and about one- 
fifth as broad as long. It often is pointed at one extremity. The 
bacilli of leprosy are morphologically almost identical with those of 
tuberculosis, but are found in affected tissues in vastly greater num- 
bers, appearing usually in clumps, and responding more promptly to 
staining and decolorizing agents. These microorganisms have been 
found in nearly all the tissues of the body, and especially in the 
skin, mucous membranes, interstitial tissue of the peripheral nerves, 
in the cartilages, cornea,- spleen, liver, lymphatic glands, sebaceous 
glands, and hair-follicles, also less abundantly in the testicles, sper- 
matic cords, ovaries, and walls of the blood-vessels. They do not 
occur in the muscles, spinal cord, bones, or joints, and are wanting 
in many secondary inflammatory lesions, such as bullse on the sur- 
face of the skin. They are rarely found in the epidermis, and 
though it is claimed that they are visible in the blood, their discovery 
in that fluid has been effected rarely. The bacilli are not found in 
physiological secretions unless these be pathologically altered by an 
organ or membrane affected with leprous infiltration. They ' have 
never been found in urine or in menstrual blood. 

The parasites are most numerous in comparatively recent but fully 
developed nodes of the skin. Such a node on section shows in the 
centre a brownish mass or " globus," which sometimes can be shaken 
out of the surrounding tissue, and which on examination proves to be 
composed almost entirely of masses of bacilli. Even in the diffuse 




1056 DISEASES OF THE TROPICS. 

form of infiltration the bacilli are usually found in groups or masses, 
but they may be disseminated through the tissues. The bacilli are 
almost invariably situated within a " lepra-cell," or occasionally in en- 
dothelial cells of the vessels, or in white blood-corpuscles. Unna, 
Schaeffer, and others, have found the bacilli without the cells. 

Unlike the bacilli of tuberculosis, those of leprosy are cultivated 
on artificial media only with difficulty; the results, according to 
Scholtz and Klingmueller, being always clouded with doubt. Cam- 

pana and Ducrey have shown cul- 
tures on blood-serum; and Emile- 
nj weil claims to have accomplished 

' j/ 'SEr ^ le same res ult with egg-agar. Ef- 

S? /° x */ forts to inoculate the lower animals 

<-** t with leprous tissue have met with 

* S almost equal failure. Nicolle, how- 
* / ever, claims to have recognized 

]§&£'■' ■'.}}, \ lepra-bacilli in mono-nuclear leuco- 

'iW:iVh^\ cytes from lesions removed sixty 

1°*° days after inoculation with lepra, 

' of the Macacus simicus. Attempts 

to inoculate human subjects with 
the disease have resulted in but one 
apparent success ; but in this case 
01 (that of a condemned criminal) 

A r'" ssrxyfsss* *™* the disease actually .*** 

oped later the results were incon- 
clusive for the reason that the man was found to have been a member 
of a leprous family. 

Introduction into living tissues of leprous material containing 
bacilli results simply in a local inflammation such as would be pro- 
duced by the introduction of any inert substance. In such experi- 
ments the leprous tissue which had been hardened for months in alco- 
hol, was equally effective with the fresh tissue. Besnier and others 
believe that the bacilli die with the tissue in which they have lived, 
and thus account for the failure of culture- and inoculation-experi- 
ments. The slight viability of the bacilli is largely responsible for 
the usual benignity and slow progress of the disease. 

In tubercular leprosy the chief histological changes are seen in 
the corium, the nodule being made up chiefly of granulation-tissue 
similar to that seen in lupus and syphilis ; but the leprous tissue is 
less vascular and consequently undergoes formative and retrogressive 
changes less rapidly ; the cells are larger than in the two other diseases 
named, and do not form nests, as in lupus. The cells, which probably 
originate in endothelial cells of the vessels or in migrated cells, are 
seen in varying sizes and usually filled with bacilli to form the " lepra- 
cells." Giant-cells are also seen. 

The infiltration may be diffuse as well as nodular, and is most 
marked at first about the vessels, glands, and follicles. Later it may 



LEPRA. 1057 

obliterate the papillae and their line of union with the rete, and ex- 
tend to the subcutaneous tissue. The external and middle coats of 
the vessels are infiltrated and thickened and their lumen narrowed. 
The sebaceous and coil-glands and the follicles are involved early, at 
first undergoing infiltration and hyperplasia, later degenerating and 
disappearing. The epidermis is involved secondarily only, and may 
be thus thinned and atrophied or broken in the formation of ulcers. 

In macular and anaesthetic leprosy Hansen and Looft state that 
" the macules are, like the nodules, leprous infiltrations of the cutis, 
consisting of round, epithelioid and spindle-cells, the latter being more 
numerous the greater the age of the macule. These infiltrations 
appear to proceed from the vessels. Lepra-bacilli are always present, 
but are most numerous in the younger macules. In the young not as 
yet anaesthetic macules the nerve-twigs appear unchanged; in the 
older ones they are usually affected." The essential nerve-changes 
are an infiltration of cells containing bacilli within the external sheath 
and between the nerve-fibres, resulting in a gradual disappearance of 
the latter as a result of pressure produced by the great increase of in- 
terstitial connective tissue. The irritation of the nerve-fibres in the 
early stages accounts for the pains and hyperesthesia ; the nerve is 
also increased in size, often to a marked degree. Later there are 
atrophy and shrinking of the nerve, of which many of the original 
fibres have been destroyed and replaced by connective tissue, with 
resulting anaesthesia. The peripheral nerves are thus frequently 
affected, but in the brain and cord leprous changes have not been dem- 
onstrated. In a few cases of anaesthetic leprosy degeneration and 
atrophy of the posterior columns, posterior roots, and spinal ganglia 
have been demonstrated, as well as other changes probably due to an 
associated tuberculosis which is not infrequently present. 

Regarding the disappearance of leprous lesions and tissue, Han- 
sen and Looft report that in both the nodular and the roaculo-anaesthetic 
forms " the bacilli in the leprous products break up into granules 
which finally disappear, and there remains of the leprous products 
only a scar in which nothing leprous can be recognized. Occasionally 
this takes place in all the affected parts, and there remains only a 
widespread anaesthesia, the result of the nerve-affection; and in the 
maculo-anaesthetic form this is the regular termination of the disease. 
In both cases the leprosy is completely healed." Jeanselme 1 con- 
cludes that after complete invasion of the subject the bacilli of lepra 
may utterly disappear, leaving only a sclerosis in their track. 

Diagnosis. — Apart from the history, present and previous places 
of residence of the subject of the disease, and the clinical symptoms 
exhibited, the diagnosis of lepra is to be established by the presence 
of lepra-bacilli. These organisms may be recognized in the tissues, 
in serum obtained from involved regions, in blood made to exude from 
lepromatous nodules, in nasal discharges, and in the secretions of ul- 
cers. Spronck asserts that the agglutinating power of the serum of 

^a Presse med., 1900, ii., pp. 375 and 388. 
67 



1058 DISEASES OF THE TROPICS. 

the leprous produces a characteristic reaction in the bacilli reproduced 
by cultures obtained by Hansen's method. 

In well-marked cases the recognition of leprosy is simple. In its 
prodromic periods no suspicion of its existence would be awakened 
in countries where the disease is not endemic. 

From syphilis, which is also a disorder the lesions of which are 
polymorphic in character, lepra can be distinguished by its much 
greater chronicity; its larger and brownish-yellow, glazed tubercles; 
its frequent paresthetic and anaesthetic symptoms ; its bullous lesions, 
rare in acquired syphilis ; the far more extended areas of its erythe- 
matous macules ; its blackish crusts, lacking the rupioid aspect of 
those in syphilis ; its leathery, mica-tinted cicatrices ; and the char- 
acteristic leonine facies of its tubercular forms. 

Morphcea and vitiligo are unattended by constitutional changes, 
and more particularly exhibit no hyperaBsthetic nor anaesthetic symp- 
toms in the affected patches. The atrophic and often deeply pig- 
mented condition of the skin in the final stages of pityriasis rubra, 
associated with the emaciation and febrile condition of the patient, 
might for a time mislead the observer who had not a full history of 
the case. Multiple sarcomata, especially upon the face, are followed 
by much more rapid degeneration and a fatal result. All lesions of 
erythema multiforme can readily be distinguished from those of 
lepra by the absence of hyperspsthetic or of anaesthetic symptoms. 

Syringomyelia is differentiated by its display of lesions only in 
regions where there is also muscular atrophy ; by the much greater 
extent and lack of definition of areas of perturbed sensation; by 
diminution of the tendon-reflexes, which may be exaggerated in 
lepra ; by a marked predominance of symptoms in the upper as dis- 
tinguished from the lower extremities; and by the frequent presence 
of scoliosis. The nodules of lupus are not symmetrical, are far softer, 
and are much more often grouped than those of lepra. Further, they 
never have the size of the larger leprous tubercles, and never have the 
peculiar pigmented, brownish, and oiled or varnished aspect of lep- 
rous nodules. 

Finally, the diagnosis of leprosy requires not only clinical symp- 
toms, but also a definite contagion. Whether a history of transmis- 
sion from one individual to another be or be not obtainable, it is cer- 
tain that no person ever manifests leprous symptoms who has not been 
infected by some victim of the disease. 

Treatment. — One of the most important considerations relative 
to the therapy of leprosy is that requiring the segregation and isola- 
tion of all lepers from contact with the uninfected. In some coun- 
tries, those particularly where leprosy prevails, wholesome laws en- 
force this separation of the infected, and charitably provide also for 
the care of the wretched victims of the disease. In America, where 
leprosy, in consequence of its relative rarity, has not yet awakened the 
attention of legislators beyond the point of forbidding the entry of 
infected persons, the proper care of lepers in a community only too 



LEPEA. 1059 

ready to take alarm even at the name of the disease, is a serious mat- 
ter. Many of the public hospitals for the care of the sick poor re- 
fuse to receive lepers. Leper homes have been established in Louisiana 
and Massachusetts. In several States of the Northwest the officers 
of health-boards are powerless to make proper provision for the care 
of a leper whose case is brought to their attention. In some of the 
American colonies provision is made for the care of lepers, as at Molo- 
kai in the Hawaiian Islands. 

The child of a leprous woman should be removed from the mother 
after birth and not be given another woman's breast. 

No remedies are known to have a directly curative effect in lep- 
rosy. As a consequence, the treatment of the disease is that suggested 
to the intelligent practitioner by the indications in each case. Most 
important, when the patient happens to reside in a district where the 
disease prevails, is change of residence and climate; the adoption of 
a highly nutritious diet ; and the exhibition of roborant remedies, in- 
cluding steel, quinine, cod-liver oil, and often the moderate use of 
wines and malt liquors. 

We have employed radio-therapy in the case of several leprous 
patients with success in the alleviation of local symptoms. Wilkinson 
also reports satisfactory results from the same measures in twelve 
reported cases, three having been scheduled as " cured " and seven as 
" improved." Lesions at a distance from those actually exposed to 
the ray exhibited improvement. 

Chaulmoogra oil, which is obtained from the seeds of Gynocardia 
odorata, has the highest reputation in the treatment of leprosy. It is 
given in milk, in emulsion, or in capsule, in doses varying from a 
few minims to 200 and even 500 in twenty-four hours. Crocker and 
Dubreuilh report instances of a cure after this treatment. 

Gynocardic acid (its active principle) is administered as a 
salt in combination with either sodium or magnesium, in doses of -J- to 
3 grains (0.033 to .2). The oil has also been injected subcutan- 
eously, 5 grammes (75 grains) daily. Strychnine is added to the 
oil with advantage in some cases. In the case of a number of lepers 
who were treated by us with chaulmoogra oil, marked benefit was 
noticeable in the course of a few months. Gurjun oil, obtained from 
Dipterocarpus Icevis, emulsified, 1 part with 3 parts of lime-water, is 
also given in \ ounce (15.) doses twice daily. Frictions with both oils 
are useful with the administration of ichthyol, 2 drachms (8 
grammes) taken internally in twenty-four hours. 

While the internal administration of mercury by the mouth has 
not been found useful, Crocker recommends injections of the bichlor- 
ide of mercury, \ grain (0.016) to 20 minims of water, in the but- 
tock twice weekly. 

Diesling in several papers has enthusiastically advocated daily 
subcutaneous injections for six weeks of a thirty per cent, emulsion 
of iodoform in olive oil, from two to eight centigrammes being em- 
ployed. 



1060 DISEASES OF THE TROPICS. 

The injection of antivenene, the Carrasquilla serum, and other 
modes of serum-therapy have not been followed by results confirmed 
by experience. The cinchonas and salicylates are indicated in feb- 
rile conditions. Mercury, quinine, arsenic, cod-liver oil, strychnine, 
the iodine compounds, hoang-nan in pills of 3 grains (0.266) ; creo- 
sote in half-drop doses (0.033) ; the oil of cashew-nut, chrysarobin, 
pyrogallol, resorcin, 10 per cent, solution of salicylic acid in oleic 
acid (Arning), have all been employed with varying success by dif- 
ferent practitioners; but an unprejudiced review of the maximum of 
results thus obtained establishes the conviction that no one of the 
remedies named may be regarded as exercising a controlling in- 
fluence over the disease. Most of them have been employed by phy- 
sicians sufficiently wise to enforce simultaneously the most generous 
tonic regimen, thus clouding with doubt a belief in the part played 
by the medicament in the production of the result. 

D. W. Montgomery, 1 Ehlers, 2 Calenheim, Thin, and others have 
reported cases both of spontaneous cure of lepra and also cures of the 
disease by medication. One such instance was shown to me by Lie in 
Bergen. 

Prognosis.- — The future of the leper is in general dark. The dis- 
ease is often malignant in character, and, however protracted, a fatal 
result has been the rule. Still, with a change of climate and im- 
proved hygienic conditions much has been accomplished. The Scan- 
dinavian lepers who have removed to the United States have been ben- 
efited greatly by the change. This was the opinion of the late 
Professor Boeck, who studied the history of leprous immigrants who 
had come to this country from Norway. He believed that the change 
in some cases would work a complete arrest of the disease. A careful 
study of the history of leprosy in America will induce the belief that 
such a favorable result can be anticipated after residence in this coun- 
try. Cases of both maeulo-amesthetic and tubercular lepra, conclud- 
ing with complete recovery are now sufficiently numerous to suggest 
that the prognosis of the malady in the future may be much more 
favorable. 

Sartian Disease (Taschlcent-geschwur) is an infectious granuloma, 
described by Herman, and microscopically examined by Rudniew. 
It occurs in Tasclikent, or Taschkend, a market-town of Asiatic 
Russia, west of the Caspian Sea. The disease affects the face, the 
upper extremities, and the trunk, avoiding always the palmar and 
plantar regions. Reddish macules develop into nodules, which des- 
quamate, coalesce, degenerate, and leave crusted ulcers, which may 
cicatrize. 

1 Med. Kec, 1902. 

2 La Lepre. 1901, ii.. p. 15; ibid., p. 53. 



YAWS. 1061 



YAWS.i 



(Framboesia Tropica; Pian ; Polypapilloma Tkopicum; Lepra 
Fungifera; Tobce; Bubas, Bouba, or Boba; Schwammfor- 
mige ; Bouton d'Amboine ; Tonga ; Coco ; Framosi ; Tetia ; 
Lupani; Tomo; Peruvian Wart; Parangi.) 

Yaws is an infectious and contagious disorder existing as endemic 
in certain tropical countries and affecting chiefly individuals of the 
colored races. 

Yaws was first given the name, Framboesia, by Sauvages in 1759, 
and has since been recognized (under many colloquial terms a few 
only of which are given above) in Northern Africa, Algeria, Mozam- 
bique, Madagascar, and the Comoro Islands, Asia, Australasia, and 
the French and English West India Islands. It is possibly identical 
with the disease described in Scotland in the year 1694 under the 
title of " sibbens " or "sivvens." 

Symptoms. — According to Castellani, whose description is for the 
most part followed in the ensuing paragraphs, a primary lesion, 
rarely genital in situation, first develops after an incubative period 
of from two to four weeks, consisting of papules, single or multiple, 
which soon become moist, secreting, and covered with a thick crust 
beneath which forms an ulcer with sharply defined edges, and a 
granulating floor. This ulcer may heal, leaving a whitish scar, or 
develop into a granulating tubercle (" mother yaw," "maman pian ") 
about which may form satellites. The neighboring ganglia may en- 
large and become indurated but do not break down. At times the 
sore is pruritic and painful. The site of the lesion is commonly 
extra-genital. The papule may develop from previously occurring 
traumatism (pustules from scabies, vaccination-wounds, insect-bites, 
etc.). In women, the mammary region and in men the extremities 
are frequent sites of the primary lesion, though it may develop on 
any part of the body. It may last from a few weeks to several 
months and may thus persist until the evolution of secondary 
symptoms. 

The ensuing generalized eruption begins within one to three 
months after the evolution of the primary sore, and may be accom- 
panied by malaise, headache, vague pains, and mild febrile symp- 
toms. The lesions are then multiple, pin-head-sized, roundish; 
papules with a yellowish apex, capped often with a thin crust of cor- 
responding hue. These lesions may enlarge to granulomatous nod- 
ules or tubercles with dark areola, the thin secretion from which 

1 Cf. Scheube, Falcke, and Cantlie, Diseases of Warm Countries, p. 290 (with 
bibliography); Manson, 1. c, p. 566; Gerrard, Jour. Trop. Med., 1906, Jan. 1; 
Wolley, Amer. Med., 1904, p. 242 (with photomicrograph of section) ; MacLeod. 
Brit. Med. Jour., 1907, Sept. 21; Castellani, Brit. Med. Jour., 1907, Nov. 23, p. 
154 (with cut showing spirochsete), J. C. D., 1908, xxvi., p. 151 (12 plates); 
Beurmann and Gougerot, Eev. de Med., 1907, May 10; Neisser (experiments in 
apes), Munchen med. Woch., 1906, No. 28; Halberstaedter, Kaiserlich. Gesund- 
heits., 1907, Bd. xxvi., Heft 1. 



1062 DISEASES OF THE TEOPICS. 

desiccates to a crust. Later, the lesions may dry into keratosic, firm 
papules which eventually shrivel, disappear, and leave at the site of 
each, deeply pigmented spots. They may last for months, may be- 
come pruritic, and may be associated with scaly and ulcerative 
patches, with granulating or irregularly outlined, nutmeg-grater-like 
areas of a whitish tint, or with papules exhibiting a central plug 
suggesting lichen spinulosus. Painful lesions occur on the palms and 
soles. The odor arising from the patient is offensive. 

A striking resemblance to some phases of syphilis is presented 
when, in the palmar regions, firm, roundish, flattened papules having 
a dense central epidermic plug, exhibit characteristic pits when the 
central plug is shed or removed. 

Alopecia occurs only in narrow areas where granulomatous 
changes have destroyed the follicles ; in rare cases the lesions invade 
the mucous surfaces where whitish patches develop. Fever when 
present is of sympathetic type merely; firm, painless, cervical and 
inguinal glands may enlarge but do not break down unless secondar- 
ily infected. Osteo-periostitis, muscular contracture, hyperidrosis, 
and chloro-ansemia may occur. 

A tertiary stage may be wholly absent, or, after some years, may 
follow the secondary phenomena described above, gummatous nodules 
invading the skin and subcutaneous structures, breaking down into 
ulcers with clean-cut edges and a sloughy floor. The resulting scars 
are whitish N in hue and correspond in outline to the preexisting 
ulcers. The scars are often disfiguring and contracted. 

Etiology and Histopathology. — Castellani has shown that yaws 
is produced by the spirochceta pertenuis, a delicate, motile, spiral- 
shaped organism, 18 to 20 microns in length, which has been stained 
by both the Leishman and Giemsa methods. The organism may 
exhibit 6 to 20 or more spirals, the extremities being usually pointed, 
occasionally pyriform. No undulating membrane has been recog- 
nized. Both Castellani and Neisser have demonstrated that monkeys 
inoculated with yaws are not immune against syphilis and vice versa ; 
though Xoisser is not in agreement with Castellani as to the proof 
that yaws is actually a treponemosis. 

The cutaneous tumors of yaws are granulomata composed of 
round and spindle-shaped elements in a vascular network of con- 
nective-tissue-cells, a plasma-cell infiltration of the skin, where the 
papilla? are elongated, and whose vessels are dilated. In advanced 
cases there is hyperkeratosis. Castellani has noted the large number 
of polychromatic red blood-cells of different sizes in films stained by 
the Leishman method. He interprets the roundish or oval rather 
deeply stained bodies recognizable in the protoplasm and nuclei of 
leucocytes, as polychromatic micro-erythrocytes engulfed by pha- 
gocytes. 

Diagnosis. — The distinction between framboesia and psoriasis and 
eczema is readily effected by consideration of the distinctive pecu- 
liarities of the several disorders named. It is chiefly the distinction 



VEBBUGA PERUANA. 1063 

from syphilis that has engendered confusion in the past. The follow- 
ing are important points of distinction: syphilis often, yaws rarely, 
attacks the mucous surfaces, the last-named disease much more rarely 
involving the lymphatic glands ; there is usually itching in the yaws 
eruption; there is no characteristic copper color in its eruptive feat- 
ures; yaws does not aifect the bones save in the continuity of long- 
standing ulceration of the skin; the subject of yaws is susceptible 
to indefinite autoinoculation ; yaws though common in children is 
not inherited; healthy parents may have infants seriously affected 
with frambesia; lastly, the two diseases often concur in the same 
person. 

Treatment. — The disease yields readily in the simpler cases to 
mild parasiticides ; in severe cases tonics are required internally, 
such as iron, quinine, and strychnine. 

Prognosis. — The prognosis is favorable save in infants and broken- 
down subjects of other maladies. 

VERRUGA PERUANA.* 

(Sp., Verruga, wart.) 
(Peruvian Wart, Oroya Fever, Carrion's Disease.) 

Verruga Peruana was described first in the sixteenth century by 
Zarate, of Lima, in his History of the Conquest of Peru (1543). 
J. J. Tschudi, in 1845 (vide infra), contributed the first scientific 
observation of the disease. It is a malady formerly widely distributed 
in certain of the valleys of the Andes in Peru, at an elevation of from 
3000 to 10,000 feet above the sea-level, the wind-protected gorges 
being endemically affected, though at present somewhat less severely 
attacked. The disease is supposed to have been observed also in 
Ecuador, Bolivia, and Chile. Stelwagon has treated one case in 
Philadelphia. 

Symptoms. — The disease is ushered in with severe rheumatoid 
pains and fever, lasting for weeks or months, the latter often inter- 
mitting, producing grave anaemia, and accompanied by splenic and 
hepatic changes. Often there are evidences of profound prostration 
with symptoms strongly suggestive of " congestive chills " in tropical 
and malarial districts. In grave cases there may be a fatal issue 
before the development of cutaneous symptoms. 

The skin-manifestations, sparse or numerous, discrete or confluent, 
may appear on subsidence of the constitutional disturbance, though 

1 Cf. Chastaing, Arch, de Med. naval., Dec, 1897, p. 417; Firth, Allbutt's Sys- 
tem, vol. ii., p. 496; Letulle, Compte Eend. de la Soc. biol., 1898, xv., p. 764; Mor- 
row's System, vol. iii., p. 694; Nicolle, Arm. de Plnst. Past., 1898, xii., p. 591; 
E. Obriozola, La Maladie de Carrion, ou la Verruga Peruv. Paris, 1898 ; Manson, p. 
580; Scheube, Diseases of Warm Countries, p. 298 (bibliography); Eamirez del 
Villar, Inaug. Diss., Berlin, 1895; Buge, Berlin, klin. Wchenschrft., 1897, p. 1005; 
Stelwagon, Diseases of the Skin, p. 793; Tschudi. Arch. f. phys. Heilk., 1845, p. 
378; Oesterreich. med. Wchnschrft., 1846, p. 505, and Wien. med. Wchnschrft., 
1872, p. 240; Godas, G-., Cron. Med. Lima, 1907, xxiv., 225, 241, 264. 



1064 DISEASES OF THE TEOPICS. 

the latter may recur after the exanthem develops. At first the lesions 
are slightly elevated, pinkish or reddish macules, which later assume 
a dusky bluish-red hue. From these spring conical, hemi-globoid 
elevations (warts) varying in size from that of peas to that of beans, 
developing later into pigeon's egg-sized, softish or elastic, smooth, 
shining, and often hemorrhagic elevations. Variations occur, when 
vesico-pustules and even large blebs form. On the summit the 
thinned epidermis commonly cracks ; the fissured apices later produce 
fungiform excrescences. The lesions may vary in number from one 
or a few to thousands, covering the entire body-surface, though the 
parts chiefly invaded are the face (especially the forehead, super- 
ciliary arch, eyelids, cheeks, nose, ears), the neck, and the extensor 
faces of the limbs, especially near the articulations. The palms, 
soles, and scalp are invaded more rarely, the trunk still more rarely. 
The lesions may be subcutaneous ; they may involve the mucous sur- 
faces, and even the viscera. Abortive eruptive phenomena have been 
noted in cases. In some instances there is distinct confluence of 
lesions; deep ulcerations eventually may furnish a fetid discharge, 
or be the seat of abundant hemorrhage. In such event the lesions are 
transformed into malignant-looking grayish or blackish spongy 
masses, covered with brownish crusts and exhaling a putrescent fetor. 

Etiology. — The disease is transmissible by inoculation, as evi- 
denced in the case of the physician Carrion, who after self-inocula- 
tion in both arms from the blood of a patient, perished in fifteen 
days. The name added to the list of titles given above, is a me- 
morial of this self-sacrifice. The disease attacks persons of both 
sexes and all ages, including newborn infants. Persons working 
in the earth are especially liable to contract the disorder, which 
seems further to be aggravated in conditions of moisture and warmth. 
Malaria is a well nigh invariable correlative of the affection. Man- 
son believes that the hemorrhagic features of the cutaneous lesions 
may be attributable in part to the rarity of the atmosphere in the 
regions where the malady exists. 

Pathology. — The pathology of the disease is that of a granuloma, 
similar in many points to the granuloma of yaws. 

Treatment. — The treatment requires removal to a climate where 
the disease is not endemic : and includes firm compression of all 
hemorrhagic lesions. 

Prognosis. — The disease may run its course in a few days or be 
prolonged for weeks or even months. One attack seems to confer im- 
munity against a second. The rarer complications of the general con- 
dition are intestinal hemorrhages, hematuria, metrorrhagia, hemop- 
tysis, epileptiform convulsions, and meningitis. In favorable cases 
the eruptive elements shrivel and scale, and become the seat of varying 
degrees of pruritus which may be excessively severe. 



ULCEBATING GRANULOMA OF THE PUDENDA. 1065 

ULCERATING GRANULOMA OF THE PUDENDAL 

(Serpiginous Ulceration of the Genitals, Groin Ulceration, 
sclerotizing granuloma of the pudenda, perforating 
Granuloma of the Thigh, Granuloma Inguinale Tropicum. 
Ger., Das Venerische Granulom.) 

In 1896 Conyers and Daniels first recorded observations of this 
disease in negroes resident in British Guiana and among East 
Indians. The malady has since been observed among the natives of 
the Fiji and Solomon Islands and the New Hebrides. Contributions 
to the subject have been made by Maitland, MacLeod, Manson, and 
others. 

Symptoms. — The disease occurs in both sexes after the puberal 
epoch, chiefly in women, and is seen most often in the genital region 
and the parts provided with long hairs, but it has been observed on 
the cheek, the lips, and inside the mouth. The lesions are vivid-hued, 
shining, verrucous, vegetating nodules of granulation-tissue. These 
are at first circumscribed thickenings and elevations. The thin over- 
lying epidermis is excoriated readily, and exposes a hemorrhagic 
surface which may ulcerate. The granuloma spreads both by auto- 
infection and peripheral extension, producing eventually, possibly 
after years of slow extension, a dense, contracting, irregularly nodu- 
lated scar-tissue, here and there sprinkled with islets of actively 
progressing disease. Unevenly pigmented areas are made up of 
excoriated or partly cicatrized and corded tissue, often with a narrow, 
serpiginous, elevated, glazed, pinkish or reddish border. The process 
is superficial and as a rule unaccompanied by coincident adenopathy. 
The parts most often invaded are the labia and vagina of women ; 
in men the penis, urethra, and scrotum ; in both sexes the ano-rectal 
region, pubes, groins, and rarely the bladder. Subjective sensations 
are not conspicuous; ansemia and cachexia occasionally result. 
Offensive discharges are produced in advanced cases. The disease is 
aggravated in regions of pressure, friction, and moisture. Manson 
describes the affected surface as " an area of white or irregularly pig- 
mented, perhaps excoriated, contracting, folded, and dense cicatrix, 
surrounded by a narrow, serpiginous, irregular border of nodulated, 
somewhat raised, red, glazed, delicately skinned or pinkish, super- 
ficially ulcerated or cracked new-growth." 

Etiology. — The disease attacks persons of all races, but chiefly 
negroes ; and individuals of both sexes, but mostly women. The sub- 
jects are as a rule young adults, though the disease is seen in aged 
persons. The affection is contagious, autoinoculable, and frequently 

1 Bibliography : Conyers and Daniels, Brit. Guiana Med. Ann., 1896, viii., p. 13. 
Crocker, Diseases of the Skin, p. 1076; J. C. D., 1908, p. 61. Daniels, Brit. 
Guiana Med. Ann., 1898, x., p. 49. Fowler, ibid., 1899, xi., p. 22. Gallowoy, B. 
J. D., 1897, ix., p. 133. K. MacLeod, Jour, of Trop. Med., 1899, p. 175. J. Mait- 
land, Lancet, 1899, ii., p. 1624. Manson, loc. cit., p. 471. A. Powell, Ind. Med. 
Gaz., 1899, p. 187. Scheube, Falcke, Cantlie, loc. cit., p. 54. Sequeira, Brit. Med. 
Jour., 1908, March 7. 



1066 DISEASES OF TEE TROPICS. 

venereal in origin though not syphilitic. The precise character of its 
virus is unknown. 

Pathology.— According to Galloway, the lesions are tumors of 
infectious granulation-tissue, which begin with a small-cell (plasma- 
cell) infiltration of the papillary layer of the corium and of elongated 
rete-pegs which crowd before them as they advance, the fibres of the 
corium. The overlying epidermis is thinned or absent; the vessels 
dilated ; the granular tissue not greatly altered. !No caseation occurs, 
and no giant-cells are seen. Donovan (cited by Manson) has recog- 
nized in scrapings from the lesions, a gigantic short bacillus, 1 by 2 /*, 
with rounded extremities, abundant in mononuclear leucocytes. 

Diagnosis. — The disease is to be differentiated from syphilis by 
the absence of adenopathy, by the extreme chronicity of the process 
(at times extending over ten years with but few changes), and by the 
special features outlined above. It is not amenable to antisyphilitic 
treatment. 

The Treatment is by excision, which Manson prefers on account 
of the marked tendency to recurrence in many cases. Curettage and 
subsequent cauterization have been successful. Mercury and iodine 
salts are of little if any value. Radiotherapy has been employed 
with success. 

ORIENTAL SORE.i 

(Mycosis Cutis Chronica, Lupus Endemicus, Aleppo Evil, 
Biskra Bouton, Delhi Boil, Oriental Button, Oriental 
Ulcer, Gafsa Button, Afghan Plague, Taschkat Ulcer, 
ISTatal Sore. Fr., Bouton d'Orient, Chancre du Sahara, 
Clou de Biskra; Ger., Endemische Beulenkrankheit.) 

The morbid condition known as Oriental Sore is one designated 
not merely by the synonyms detailed above, but by a series of names 
in the Arabic, Turkish, Persian, and Russian languages which in 
most instances refer to the same disease. It is an endemic cutaneous 
affection, recognized chiefly in tropical and subtropical countries, 
more particularly in those which have given titles to the disease, such 
as Biskra, Gafsa, Aleppo, Bagdad, Delhi, etc. It occurs in Morocco, 
Algiers, Tunis, Egypt, Crete, Cyprus, the Crimea, Syria, Mesopo- 
tamia, Arabia, Persia, Turkestan, India, Brazil and probably other 
portions of South America. 

Symptoms. — The disease begins after an incubation period of days 
or months as a circumscribed pruritic maculo-papule having a firm, 

^cheube, Falcke, Cantlie, Diseases of Warm Countries, Phila., 1903, p. 534 ; 
Manson, p. 589, Brault, Annales, 1899, s. iii., x., p. 85 and p. 226; Brocq et Veillon, 
ibid., 1897, s. iii., viii., p. 553; Doulas, Jour. Mai. cutan., 1903, s. vi., xv., p. 190; 
Kuhn, Johanne, Virehow's Archiv, 1897, p. 372; Lemarsky, Eev. internat. de 
Med. et de Chir., 1897, viii., p. 78; Lowenhardt, Eep. Trans. Germ. Assoc, of 
Surg., xxviii., Congr. 1899, p. 37; Morvan, J. C. D., 1900, xviii., p. 230; Moty, 
Annales, 1893, s. iii., iv., p. 41, and 1897, s. iii., viii., p. 726; Eiehe, Vierteljahr., 
1886, xiii., p. 805; Unna, Histopathology, 1894, p. 472; Wright J. C. D., 1904, 
xxii., p. 1 ; Nattan, Larrier, J. A. M. A., 1907, Sept. 14, p. 972. 



ORIENTAL SORE. 1067 

shot-like feel, starting from an hypersemic and infiltrated portion of 
the skin. In the course of a few days furfuraceous scales cover the 
surface of a well-defined papule, which being agglutinated by the 
secretion from beneath of a thin fluid, form a yellowish-brown thick 
adherent crust. On the removal of this crust there is exposed be- 
neath, a shallow ulcer which extends peripherally and exudes a secre- 
tion which tends to reproduce the crust, beneath which the ulcer 
spreads. Satellites in the form of new papules and ulcers form in 
the vicinity which often merge and produce a single, sharp-bordered, 
rounded or oval, punched-out ulcer with granulating floor, cedematous 
base, out-lying areola, and bulky crust. The dimensions of the sore 
vary from 8 to 12 or more centimetres in diameter. Repair after a 
period of from two to twelve or more months ensues by the usual 
processes of granulation and cicatrization. The resulting cicatrix is 
usually sunken, at first pigmented, and exceedingly deforming when, 
as is often the case, it is displayed upon the face. 

The parts chiefly affected are the face, especially in young sub- 
jects, the hands, feet, arms, and legs; commonly the palms and soles, 
the scalp, and trunk are spared. In some cases the primary lesion 
does not proceed to ulceration ; in yet other cases, instead of one there 
may be a dozen or even forty separate sores ; the lesion, like all 
others, may be complicated by the epiphenomena of erysipelas, pha- 
gedena, lymphangitis, abscess, phlebitis, etc. Relapses occur. 

Etiology. — Oriental sore is contagious, auto-inoculable, and trans- 
missible to and from the lower animals by direct contact or by the 
medium of insects, articles of clothing, etc. It affects indiscrimi- 
nately persons of both sexes, of all ages and nationalities, those vary- 
ing as to vigor and occupation. It often attacks children after the 
completion of the second year, and seems at times to confer a species 
of immunity against second attacks, though many instances tend to 
disprove the possibility of such protection. Those exposed may 
develop symptoms in the course of a fortnight ; though in other cases 
it would seem that months may intervene before infection is estab- 
lished; briefly there is no fixed period of incubation. 

Nicolle and Sicre 1 report the transmission of oriental button 
from a man to an ape (Macacus simicus), lesions appearing twenty- 
four days after infection. 

Pathology. — Parasites taking a violet stain were recognized by 
Cunningham and Firth. Wright, in the case of a female child nine 
years of age, born in Armenia, examined a tropical ulcer which was 
excised, and recognized in smear preparation round, well-defined 
bodies 2 to 4 ^ in diameter, each containing a lilac-colored mass near 
the periphery of the body, which were present in large numbers and 
supposed to be protozoa (Leishman bodies). They were recognized 
as intercellular in situation, and multiplied by fission without spore- 
formation. Wright gave the name helcosoma tropicum to these 

1 Compt. rend, la se. Soc. Biol., lxiv., 1908; abstr. Dermat. Centralb., 1908, 
xii., p. 17. 



1068 DISEASES OF THE TROPICS. 

bodies, and believes them to differ from the organism recognized by 
Firth by reason of the characters described above. These observa- 
tions have been confirmed by Nathan Larrier. He found the organ- 
isms in the blood and phagocytes, the macrophages disappearing later 
and replaced by lymphocytes. The disease is probably propagated 
by blood-sucking insects. 

Sections made of primary papules reveal round-cell infiltration 
of the derma, the presence of multinuclear and giant-cells, and of 
leucocytes, the deposit being most plentiful about the vessels of the 
skin and the coil-glands. In the midst of the infiltration Unna has 
seen necrotic granules ; the surviving hairs are altered in shape and 
sheath ; rounded or oval cavities surround the hair-pouches ; the 
blood-vessels may be obliterated by endothelial plugs. 

Diagnosis. — The diagnosis in localities where the affection is en- 
demic is attended with but little difficulty; but among the classes 
in which the disease is especially likely to be encountered, it is con- 
founded most often with syphilis. The strictly local character of the 
oriental sore and the duration of that disease furnish ample facility 
for its distinction from other ulcers of a specific origin. 

Treatment is by cauterization, excision, erasion, asepsis, and the 
methods employed by the resources of modern surgery in the manage- 
ment of similar affections. By many local authorities the milder and 
soothing rather than the more severe (destructive) measures of treat- 
ment are advocated. Continuous immersion should be employed in 
all severe cases. 

Prognosis. — The prognosis is in general favorable, save in the 
matter of deformity left by the resulting scars. Crocker's patient 
after excision of the sore died of general sarcomatosis. 

BUCHAREST BOIL. 

Finkelstein 1 describes under this title a painful furuncular affec- 
tion differing from the oriental sore, preceded by pain and beginning 
with an elevated nodule which in the course of two or three weeks, 
during which period there are accesses of fever, bursts and after dis- 
charging leaves a contracted cicatrix which may also be complicated 
with articular anchylosis. The abscess may be as large as a child's 
head, and commonly is situated either in the inguinal or lumbar 
region. The subjects of the disease are usually between eighteen and 
thirty-five years of age, suffer but little in the general health, and 
rarely perish of the affection, which is believed to originate in un- 
sanitary conditions of living. Frankel's pneumococci, the common 
streptococci, and staphylococci have been found in the pus. No 
malarial parasites have been recognized. 

1 Deutsch. med. "Wochenschrft., 1899, cited by Scheube. 



PELL AGE A. 1069 

TROPICAL DISEASES OF UNCERTAIN NATURE. 
PELLAGRAL 

(Lat., pellis, the skin; ceger, diseased.) 

(Lombardy Erysipelas, Lombardy Leprosy, Bjsipola Lombarda, 
Lepra Italica, La Kosa, Mae Koxo, Pellarella, Alpine 
Scurvy, Dermatagra.) 

This is a chronic constitutional disorder prevailing as an endemic 
in various parts of Europe, Asia, Africa, and North America, char- 
acterized by gastro-intestinal, nervous, and other morbid symptoms, 
being also accompanied by an erythematous exanthem. The disease 
is recognized chiefly in Italy (Lombardy, Venice, Emetta), but 
occurs also in parts of Spain, France, Portugal, lower Egypt, and 
Mexico (Yucatan, Campeche). Sherwell has reported cases of the 
disease occurring in Italian sailors visiting New York City, and 
Seavey 2 reports cases of pellagra in Alabama. The medical officers 
of the South Carolina State Hospital and elsewhere, including those 
of the city of Chicago, have recognized the disease in patients under 
their care. 

Symptoms. — The symptoms of pellagra differ to a marked degree 
in different subjects of the disease and in the different countries in 
which it is endemic. The course of the malady is essentially chronic, 
and is characterized by remissions and aggravations in recurrent 
attacks. There is commonly a prodromic stage, of longer or shorter 
duration, which may extend over several winters preceding the spring 
in which most often marked symptoms are declared. The subjects 
of the affection then experience languor, suffer from vague pains in 
various parts of the body, and are disinclined to labor by reason of 
bodily weakness. These recurrent evidences of ill health are followed 
by marked anorexia, thirst (often intolerable), or inappetence for both 
food and drink, abdominal pains, eructation of gas, and loose stools, 
often with bloody alvine evacuations. These signs of disorder are 
accompanied generally by nervous symptoms, including pains and 
tenderness of the head, vertigo, dizziness, marked asthenia, mental 
dejection and hebetude, with increase of the tendon-reflexes and inco- 
ordination of movements, more particularly of the lower extremities. 

1 Bibliography : Gemma, Ann. univ. di med., 1871, p. 564; Winternitz, Vier- 
teljahr., 1876, iii., p. 151; Paltauf u. Heider, Der Bacillus Maidis (Caboni) und 
seine Beziehungen zur Pellagra, Vienna, 1889; Eaymond. Annales, 1889, s. ii., x., p. 
627; Pellizzi, u. Tivelli, Centralbl. f. Bakt. u. Parasit., 1894, xvi., p. 186; Carravoli, 
Giorn. della r. Soc. ital. d'igiene, 1896, Nos. 7-9; Lombroso, Die Lehre von der 
Pellagra, Berlin, 1898 ; Sandwith, B. J. D., 1898, x., p. 395, and Jour. Trop. Med., 
1898, i., p. 63; Babes and Sion, "Pellagra," NothnageFs Spec. Path. u. Therapie, 
xxiv., Pt. ii., fasc. iii., Vienna, 1901; Scheube, Palcke, and Cantlie, Diseases of 
Warm Countries, Philadelphia, 1903, p. 311; Ceni, Centralbl. f. Allg. Path. u. 
path. Anat., 1903, xiv.,p. 465; Galli, Med. Wchnschrft., 1901, Nos. 34 u. 35 (abstr. 
Archiv, 1903, lxvi., p. 263) ; Verotti, Giorn. internat. d. Sc. Med., Napoli, 1903, 
xxv., p. 273; Stefanowitz, Wien. klin. Wchnschrft., 1903, xvi., p. 1089. Manson, 
1. c, p. 328. 

2 J. A. M. A., 1907, July 6, p. 37. 



1070 



DISEASES OF THE TSOPICS. 



The cutaneous symptoms may be a marked feature of the disorder 
or be wholly lacking. The skin, especially of exposed regions, such 
as the face, neck, upper chest, backs of the hands, lower third of the 
forearms, dorsum of the feet, and in the case of persons who are al- 
most entirely nude during the day, such as the Fellahs of Egypt, the 
entire body area becomes involved. The surface is then reddened 

Fig. 217. 




V. S., aged twelve years; acute pellagra: death in first attack, 
i \v. J. ii. Bellamy.) 

in patches of irregular contour, tumid (toxic erythema), and either 
smooth or disclosing the usual signs of dermatitis (vesicles, blebs, 
pustules, crusts, etc.). As the subacute attack subsides usually in a 
fortnight, there follow desquamation, pigmentation, harshness of the 
surface, and the condition commonly following repeated attacks of 
dermatitis, the skin becoming shrunken, wrinkled, atrophic, and 
xerodermatous. 

The other pronounced symptoms of pellagra are marked sensori- 
motor phenomena (muscular weakness, at times amounting to paraly- 
sis : tremor or tetanic contractions ; para?=thesie diplopia, hemeralo- 
pia, melancholia, and imbecility ). At times dementia follows. The 



PELL AGE A. 1071 

coordinate symptoms may be fever, in varying gradations of temper- 
ature, and marked circulatory changes. 

In the final stages of the disease cachexia is induced and the 
patient falls into a condition of marasmus (typhus pellagrosus) with 
the usual signs of extreme weakness (involuntary defecation and uri- 
nation, sordes on the teeth, intercurrent pneumonia, or other fatal 
complication). 

Within a relatively brief period cases of pellagra have developed 
in America chiefly in the southern states, so far as known for the 
first time in the medical history of the country. 1 The cases have 
occurred in a somewhat acute type and almost in the form of an 
epidemic, with a mortality somewhat greater than that recognized 
in European cases. The history of this disorder in America would 
seem to indicate that Manson's disbelief in the origin of the disease 
should be accepted with reserve. The origin of some of the Ameri- 
can cases has been distinctly traced to the consumption of maize 
producing a toxine after its storage. 

The disease may recur annually and thus persist until the 
strength of the victim is exhausted for from two to ten or more years. 
An acute form (pellagra typhus) may give rise to high temperatures 
of the body, delirium, trismus, and opisthotonos. 

Etiology and Pathology. — Pellagra has long been believed to 
arise from the consumption of damaged maize, but the arguments 
against this theory are both numerous and cogent, and are well set 
forth by Manson who details conditions cited as effective in maize 
supposed to have morbific effects. These are : deficiency in nutritive 
elements ; toxic substances in normal grain ; toxic substances sup- 
posed to be elaborated after its ingestion ; substances produced during 
decomposition of the grain ; and fungi or bacteria found upon it. 
Reviewing the entire question it appears that the efficient factor in 
the production of pellagra is at present unknown. 

Persons of both sexes are prone to the disease after reaching 
adult years, infants being rarely attacked. The disorder is practi- 
cally confined to field laborers, the Jews who are no longer an 
agricultural race, and urban populations in general, being largely 
exempt. It seems tolerably clear that insolation has some influence 
in its production, seeing that the exposed parts of the body especially 
in the months of the spring season, suffer extensively and this at 
recurrent seasons in low-lying districts of country with a high water- 
level. 

Post-mortem there have been recognized: fatty and atrophic 
cardiac changes ; brown atrophy and fatty degeneration of the liver ; 
cirrhosis of the kidney ; intestinal attenuation and ulceration ; hyper- 
emia, anaemia, oedema of the brain, cord, and meninges, symmetrical 

1 J. A. M. A., 1908, Feb. 8, p. 459; Bellamy, ibid., 1908, Aug. 1, p. 307; 
Lavinder, U. S. Public Health and Marine Hospital Service; Wash. Govt. Printing 
Office, 1908, with cut; W. W. Eoy, Amer. Jour, of Insanity, Baltimore, 1907-8, 
lxiv., pp. 703-725; Thermeli, Tr. Am. Derm. Ass., 1903, p. 76; Harris, Am. Med., 
iv., p. 99 (Georgia case); Learey, J. A. M. A., xlrx., pp. 1, 37 (Alabama cases). 



1072 DISEASES OF TEE TROPICS. 

sclerosis of the cord ; and, in typhoid cases, acute myelitis. The most 
constant and pronounced of these morbid conditions are symmetrical 
sclerosis of the posterior columns of the cord, corresponding with the 
track of the lateral pyramidal fasciculus. 

Nicolas and Jambon 1 reviewing the literature of pellagra and its 
concomitant symptoms both in the skin and its mucous membranes, 
conclude that careful examination does not permit a precise clinical 
distinction between true pellagra which seems of late to have in- 
creased in frequency and the pseudo-cases given the same name. Im- 
proper food, psychical depression, poverty, and the general causes of 
malnutrition are effective perhaps to a greater extent than chemical 
changes which have thus far been recognized in the maize consumed, 
thus agreeing to a large extent with the conclusions of Manson. 

Diagnosis. — As the cutaneous lesions are at times wholly absent, 
the recognition of the disease depends for the most part on the other 
morbid symptoms presented. The region in which an endemic influ- 
ence is exerted is of importance in determining the character of any 
case. 

Treatment. — The treatment is by prophylactic improvement of 
the hygienic and climatic conditions of the patient; quinine and 
tonics in cases of debility ; proper management of nervous and gastric 
troubles ; and, when practicable, a generous dietary. Lombroso 
recommends arsenic internally, and the tincture of cocculus (gtt. 
v— x) in the treatment of giddiness. The spinal symptoms are man- 
aged best by massage, electricity, and alcoholic or salt embrocations. 

Prognosis. — The prognosis is favorable in some cases, which may 
be so mild as to be scarcely noticeable ; in others it is grave ; and in 
districts where the disease prevails extensively the mortality may be 
formidable. 

CRAW-CRAW.? 
(Kro-kro, Kra-kra. Fr.. Papulose filariexxe.) 

Craw-craw is a term employed by the natives of the West African 
coast for the designation of several diseases of the skin, including 
scabies, ringworm, eczema, and dermatites of various types, occur- 
ring among negroes. Most authors agree that great confusion pre- 
vails respecting the affection to which the name should strictly be 
limited. 

O'Neil believes that the title includes a disorder attributable to 
the presence of a filariform parasite, pustules and papules similar to 
those found in scabies occurring in the regions affected. The filarise 
found by him in the summit of scraped papules were from M.00 to 

1 Annales, 1908, s. iv., ix., p. 480; complete bibliography to date. 

2 Brault. Annales, 1899, s. iii., x.. p. 226. Collineau, Kev. Mens, de PEcole 
d 'Anthropol. de Paris, 1900. p. 84. J. Emily, Arch, de Med. naval., 1899, Ixxi., 
p. 54. Manson, 1. c, p. 794. Scheube, Falcke, and Cantlie. Diseases of Warm 
Countries, p. 522. O'Neil. Lancet, 1875, i., p. 265. Plehn, Die Kamerun-Kiiste, 
Berlin. 1898, pp. 286, et scq. 



CLIMATIC BUBO. 1073 

%ooo of an inch in dimensions, with two black markings at the 
cephalic extremity. The eruptive symptoms declined when the sub- 
ject of the disorder visited a cooler climate and returned when there- 
were fresh exposures to tropical temperatures. Manson suggests 
that the parasite may have been iilaria perstans. 

Emily describes craw-craw as beginning with the appearance of 
reddish-tinted macules of a pruritic character, ultimately forming 
large, coin-sized ulcers, with reddish areolae, clean-cut edges, and 
granular secreting floor furnishing a dense crust. 

The ulcers of craw-craw are commonly multiple, may occur on 
any part of the body, but especially upon the limbs, and are compli- 
cated and massed by the results of scratching, as the itching is often 
intolerable. 

The " Coolie-itch," described by Kicholls, is a strictly papular 
disease, without development of vesico-pustules. 

Scheube and his colleagues believe that Plehn's Dermatitis nodosa 
observed on the Cameroon coast, is wholly different from craw-craw, 
though described under that name. The former is a strictly papular 
disease, the nodules being pin-head to pea-sized, occurring on the 
inner faces of the thighs, the scrotum, the inguinal folds, and the 
gluteal region. About two out of ten negroes are affected. The 
disorder is distributed by scratching. No iilaria? were discovered. 

Etiology. — The exact cause of the disease in all probability differs 
in different cases. The affection, as described by all writers, is both 
contagious and auto-infectious. 

Treatment is by cleanliness and the employment of appropriate 
parasiticides, as boric and carbolic acids, and solution of corrosive 
sublimate 1-1000. 

Prognosis is, in general, favorable, though in some of the cases 
described by Plehn, the patients were in a pitiable state. 

CHAPPA. 

Chappa is a disorder described by Read (vide Manson) occurring 
in the Lagos Colony, characterized by severe muscular and articular 
pains, with swelling of the joints and development of multiple pig- 
eon's egg-sized nodules, subcutaneous in situation, over different parts 
of the body. The nodules burst, leaving ulcers with a " fatty-look- 
ing" base. The ulcers may fuse and become serpiginous. Other 
nodules may undergo resolution. Manson believes that the disease 
may be a tertiary phase of yaws. 

CLIMATIC BUBO. 

Under this title has been described a species of non-venereal 
inguinal adenopathy occurring chiefly among the crews of ships 
touching at African, Chinese, Japanese, and West Indian ports. 

68 



1074 DISEASES OF THE TEOPICS. 

Symptoms. — The disease is reported as beginning with remittent 
febrile symptoms associated with sub-acute crural or inguinal 
adenopathy affecting one or both sides of the body (groins or crural 
regions) the swelling at times being of the size of a hen's egg. 
After weeks or months there may be subsidence of the glandular or 
peri-glandnlar infiltration : in other cases, suppuration occurs, and 
the disease may be terminated with surgical interference: or fistulous 
tracts may form which untreated persist for long periods of time. 

Jackson properly points to the impropriety of the name by which 
the disorder has been described by Scheube. The disease is appar- 
ently non-climatic. Hanson suggests that the adenitis may result 
from a virus introduced by the bites of insects on the lower extremi- 
ties or genital region. 

Treatment. — The treatment in the acute stage is by hot bichloride 
fomentations with supporting general measures and surgical inter- 
ference when this is indicated. 

GOUNDOU.^ 

i Axakhee: Hexpfyf; Big xose ; Dog xose. Ft., Geos xez.) 

Goundou is a disease first described by MacAlister in 1882. 
chiefly exhibited in the dark-skinned races, occurring at first in child- 
hood with more or less persistent cephalalgia soon followed by a 
purulent rhinitis and the development of symmetrical, bean-sized and 
larger tumors on the sides of the nose, due apparently to a specific 
osteitis of the nasal process of the superior maxilla. The nasal ducts, 
and the skin over the tumors are apparently spared. As the disease 
progresses, the swellings may become as large as a hen's and even an 
ostrich's es:2:. 

Wellman disposes of the several theories that the disease is a 
species of yaws; of atavism due to a tribal peculiarity; that it is 
due to syphilis, to non-union of the nasal and frontal bones, or pro- 
duced by larva 3 in the nostrils. 

The pathology, etiology, and proper treatment of goundou are 
unknown. 

AINHUM.2 

(From a Nagos term, meaning "to saw. ") 

(Dactylolysis Spoxtaxea ; Baxko-kerefde ; Sfkiia pokla ; 
Qfijila. Ger., Absagex.) 

Ainhum is an affection of the colored races chiefly, especially of 
the negroes of the West African Coast, as also of the natives of the 

1 Literature: Manson. loe. eit.. p. 79S; Jackson, loc. cit., p. 495; Wellman, J. A. 
M. A.. 1906. p. 636; Maxwell. J. of Trop. Med., 1900, Nov. 11 and Dec. 15; 
Lamprey. Brit. Med. Jour.. 1SS7. Dec. 10. 

1 Manson. p. S02 : Scheube. p. 564: Hirsch. Handbuch der hist.-geog. Pa- 
thologic 186. iii.. p. 504; Moriera. Monatshefte. 1900, xxx, p. 361; Herrick, 
Phila. Med. Jour.. 1S98, i., p. 246. 



AINHVM. 1075 

Soudan, of Algiers, Egypt, the Transvaal, and, next to Africa, of the 
inhabitants of Brazil, though it has been reported in Rio de Janeiro, 
Buenos Ayres, the Antilles, and British Guiana. The disease was 
first described and named by Dr. Da Silva Lima. 1 It is possible 
that Clarke 2 may have observed the same or a similar condition, 
described by him as a dry gangrene of the little toe. 

American cases have been reported by Herrick, Shepherd, Matas, 
Hornaday and Pittman, Wheatland, and Brayton. 3 Though most 
of the patients have been negroes, it has been recognized in a few 
cases in white subjects. 

Symptoms.- — Ainhum affects the smaller digits, chiefly the little 
toe, but also other toes and fingers, sometimes one or more of the 
digits of the same foot or of both feet being involved simultaneously 
or successively. The onset is by the development of a furrow or 
shallow groove on the plantar face of the toe or palmar aspect of 
the finger near the digito-plantar or digito-palmar web. This furrow 
gradually deepens and spreads in a circumlinear direction until the 
digit is girdled by a constricting and indurated ring in the form of 
a superficial depressed gutter. The segmented portion of the digit 
becomes swollen, in consequence of the constriction, to twice or sev- 
eral times its normal size; and in time, usually in the course of two 
to ten years, the segmented part, at first resembling a small potato 
attached to a slender pedicle, drops from its original attachments. 
In this way a species of spontaneous bloodless amputation is effected. 
The nail of the member that is about to be detached by this process 
usually turns outward, the digit being commonly laterally everted. 
The changes in the segmented part, both in the nail and the tissues 
of the phalanges, are those naturally arising from strangulation of 
the member. The disarticulation may be effected at the first, second, 
or third joint: or even in the continuity of the phalanx. There is 
little pain save such as is produced mechanically by the use of the 
foot or hand from which the digit depends. Occasionally ill-con- 
ditioned and foul-smelling ulcers develop. In rare cases ulceration 
persists in the site of the wound left after separation of the digit. 

In some instances trophic, vasomotor, and sensory changes, par- 
ticularly of the limb where ainhum is progressing, are striking 
features of the case. The skin of the part may be pigmented, 
scaling, wrinkled, puckered, with wasted muscles, or covered with an 
unusual pilary growth, the tendon-reflexes obliterated, and sensibility 
decreased. Thickening and shortening of the foot, flattening of the 
plantar arch, and palmar and plantar keratoses may be conspicuous. 
We have seen three cases in white subjects (one in France) where 

1 Gazeta Med. da Bahia, 1867, Nos. 13 and 15. 

2 Trans. Epidem. Soc. of London, p. 105. 

z Cf. Da Silva Lima, Arch, of Derm., 1880, Oct., and several other communica- 
tions by the same author; Shepherd, Amer. Jour. Med. Sci., 1887, Jan. (with cut) ; 
Eef. Handbook of Med. Sci., Art. Ainhum, with four cuts; Hornaday and Pittman, 
N. Car. Med. Jour., 1881, Sept.; Brayton, J. A. M. A., 1905, July 8 (with cut); 
Wellman, J. A. M. A., 1906, Mar. 3, p. 636 (with analysis of etiologic theories) ; 
Wheatland, J. A. M. A., 1905, Aug. 26, p. 631 (with cut). 



1076 DISEASES OF THE TROPICS. 

there was coincident palmar and plantar keratosis obviously of the 
same character as that to be recognized in the dense sclerotic ring 
which was working the amputation of the digit. 

Etiology. — The disease occurs more often in male subjects of the 
African race, and in adults; but is recognized also in children, and 
quite rarely in the white races. Wellman reviews the several argu- 
ments urged in explanation of the disorder and disposes of the 
theories that ainhnm is a leprous lesion : that it is a trophoneurosis : 
that it is the result of self-mntilation : and that it is a circumscribed 
scleroderma. He believes with Manson that continued irritation 
produced by wounds of the foot in sharp grasses in the dark-skinned 
races prone to the production of keloid, is responsible for the dis- 
order. He also suggest that the chigger may be at times a factor 
in its production. In some instances the disease would seem to be 
hereditary as there are reports of families every member of which 
has suffered. In other instances several members of two generations 
of a single family have developed ainhnm. 

Pathology. — The constricting ring is composed invariably of fib- 
rous tissue, surmounted by a thickened epidermis. There is com- 
monly an increase of the subcutaneous fatty tissue. The bones ap- 
parently suffer secondarily from the constriction. 

Treatment. — The treatment required in well-marked cases is bj 
surgical removal. Prophylaxis is by protection of the feet. 

Prognosis. — The disease progresses slowly; relapses are rare; the 
process in general ends with removal of the constricted member. 

GANGOSA. 

Gangosa is a disorder endemic in certain countries such as 
Bolivia, the Philippine and Caroline [slands, British Guiana, 
Jamaica, and other parts of the West Indies, but especially in the 
island of Guam, where it is -aid to have existed for the last 150 years. 

The disease in many of its feature- strongly suggests rhinoscle- 
roma, a malady with which some authors hold it to be identical. 

Symptoms. — Gangosa i> characterized by a destructive ulceration 
commonly beginning by attacking the soft palate, pillars, or uvula 
and extending thence to the hard palate, and the nasal cavity, down- 
ward to the larynx and upward to the face. The destructive process 
is either acute or chronic and may terminate either by cicatrization 
or by extensive destruction of tissue with mutilation. Constitutional 
symptoms are wanting or developed in very mild forms. 1 

Geiger recognizes three types of ulceration of the upper air- 
passages common in the island of Guam: (a) Septic forms due to 
the usual pyogenic organisms; (b) ulcerations that are obdurate to 

1 Mink & McLean. J. A. M. A., 1906. Oct. 13, p. 1166 and supplementary paper, 
J. C. D., 1907. November; Fordvce and Arnold, J. C. D., 1906, January*; Leyea, 
Jour. Trop. Med., 1906. Feb. 15 ; Semi. J. A. M. A., 1908. Jan. 11. p. 116; Geiger, U. 
B. X. Med. Bullet.. Jan., 1908; E. K. Stitt, J. C. D.. March. 1908. p. 103. 



GANGOSJ. 1077 

antiseptic treatment, a group inclusive of most forms of gangosa. 
An organism closely resembling the bacillus of diphtheria, lias beer 
recognized in every case examined, and was found in pure culture 
in the conjunctival sac when the eyes were involved. In a third 
group, distinct nodules or tubercles develop, involving the skin or 
mucous membrane of the nose, soft palate, pharynx, larynx, or lips. 

Fig. 218. 




Gangosa. (Forbyce.) 

Diagnosis. — The disease is to be distinguished from blastomycosis, 
leprosy, rhinoscleroma, actinomycosis, lupus, and syphilis. With 
respect to the last named disease syphilis is said not to exist upon 
the island of Guam, where from one to nearly three per cent, of the 
population have gangosa. 

The disease is contagious, transmissible by direct contact, and is 
diminishing in those places where patients are segregated. 

Treatment is unsatisfactory. Mercury and iodine internally are 



1078 



DISEASES OF THE TBOPICS. 

Fig. 219. 




Showing the diffuse infiltration <>f the corium 
The vessels are the seat of an endarteritis. 
(Fordyce.) 



with round, plasma, and giant cells, 
many of them being obliterated. 



Fig. 220. 




Gangosa. 

Tropical ulceration involving nose, pharynx, and larynx. Hyperplasia and down- 
growth of the epidermis with cellular infiltration of round, plasma, and giant cells in 
the corium. (Fordyce.) 



GAYLE. 1079 

of little value. The best results are secured by antiseptics and care 
of the general health. 

VELD SORE (NATAL SORE). 

(Barkoo; Barcoo Bot, of Queensland.) 

Under this title has been described a disorder which seems to be 
related to the Oriental Boil which Crocker 1 reports as somewhat com- 
mon among the medical officers and soldiers of the English army dur- 
ing their late war in South Africa. It most often attacked cavalry- 
men. As distinguished from the Natal Sore which was chiefly found 
in the lower part of that country, the Veld Sore was most abundant in 
the high barren table-lands. Multiple lesions appear on the hands, 
forearms (chiefly on the backs), feet, and legs, but were rare on the 
face and exposed portions of the body. They commonly resulted from 
an infected invasion atrium to which the large horse-flies of that re- 
gion had access. A pinhead-sized pruritic papule, vesicle, or pustule 
first appeared subsequently enlarging and filling with a yellowish 
serum which became later turbid, ruptured, and left a small to large 
coin-sized, painful, crusted ulcer, exuding sero-pus and often accom- 
panied by inflammation of the lymphatics and glands. In some cases 
the back of the hand was entirely covered. A diplococcus was found 
growing freely in ordinary media somewhat resembling staphylo- 
coccus aureus. Crocker is inclined to believe that the disorder is a 
variant of impetigo contagiosa. 

The usual treatment of such infected lesions (boric and carbolic 
acid fomentations and ointments) was speedily effectual. 

GAYLE. 

Crocker, 2 under this title, describes an affection of ewes in the 
lambing season who are liable to a species of puerperal disorder un- 
doubtedly infective. Men who have skinned the animals dead of 
the disease have suffered by inoculation, producing at the site of the 
infection, a flat-chambered vesicle or bleb, slightly depressed at the 
centre, a centimeter or more in diameter, bluish-gray in color, sur- 
rounded by a halo,^and containing clear or blood-stained serum. 
There is apt to be axillary adenopathy; the hand may swell. Klein 
has demonstrated the staphylococcus hemorrhagicus. In some cases 
there is pain and mild fever. 

Treatment has been by sublimate lotions. 

1 Diseases of the Skin, 3d ed., 1903, p. 1075. 

2 Ibid., p. 509. 



CLASS XI. 

DISEASES OF THE MUCOUS MEM- 
BRANES IN PROXIMITY TO THE 
SKIN, OCCURRING IN ASSOCI- 
ATION WITH DERMATOSES. 



The anatomy of the mucosa in general does not differ greatly from 
that of the integument. It possesses a proliferating basal layer of 
cells, the daughter-cells of which become differentiated so as to form 
finally a superficial protective layer composed normally of nucleated 
cells smaller than those recognized in the epidermis of the skin, but 
destitute of prickles and not containing keratin. The transitional 
layers of the epidermis are not present in the mucosa and, therefore, 
keratohyalin and eleidin are absent. The cells which correspond to 
the stratum corneum are more moist and on account of the absence 
of keratin are not so resistant. The daughter-cells after differentia- 
tion appear as large cells with small, nuclear, scanty, peripheral pro- 
toplasm with a relatively large, clear, perinuclear space. In the 
deeper portions the intercellular lymphatic spaces are well-defined 
and are crossed with prickles. In some pathological conditions where 
the mucosa becomes thickened, the differentiation of the cells pro- 
gresses to a point where definite prickles are formed and the elements 
of the protective layer much more closely resemble those of the stra- 
tum corneum of the epidermis. 1 

DISORDERS OF THE CONJUNCTIVA AND EYELIDS. 2 

Demodex Folliculorum. — The hair-pouches of the eyelids are occa- 
sionally invaded by the Demodex folliculorum. 

Trichiasis. — The hairs growing upon the edges of the lids in some 
cases become incurved and ingrowing, with the result of producing 
severe local irritation, both in the lid and ocular globe. In aggra- 
vated cases the hairs have to be removed by the methods available in 
electrolysis. 

" Eczematous Conjunctivitis." — In eczematous disorders of the 
face, an efflorescence, beginning with millet-seed-sized points, may pro- 
duce a distinct elevation of the conjunctival surface with vascular in- 
jection, and an exudate not different from that seen upon the skin. 

1 References: Quaide, B. J. D., 1908, xx., p. 242; Macleod, ibid., 1899, xxi., p. 
137; Rauseh, Monatsh., 1897, xxiv., p. 65. 
2 Cf. Fuchs, Ophthalmology, 3d ed., p. 110. 

10S1 



1082 DISEASES OF THE MUCOUS MEMBRANES. 

There is usually moderate infiltration, profuse lachrymation, and 
some photophobia. 

The most of authors on this subject regard this as one of the fre- 
quent ocular diseases of youth and childhood, occurring in the scro- 
fulous and particularly in children who are insufficiently nourished 
and in an unhygienic environment. Patches of weeping eczema 
are usually found in these cases over other portions of the body, es- 
pecially the face; and the nose and upper lip are often irritated by the 
resulting coryza. 

The disease is usually relieved in a short time by protection of the 
eye and dusting with very finely levigated calomel; or the applica- 
tion of white precipitate ointment, one to two grains (.06 to .013) to 
one drachm (4.) of fatty base. 

The Exanthemata. — Among the exanthemata, measles is most com- 
monly productive of conjunctivitis in connection with the cutaneous 
exanthem. In variola the pustules not rarely develop on the conjunc- 
tiva, generally upon the tarsal surface. In some cases a purulent 
keratitis results. 

Acne Rosacea. — The lesions of this disease occur chiefly in adults 
who are suffering at the time with rosacea. The disease is charac- 
terized by the formation of minute nodules upon the conjunctival 
surface productive of considerable irritation. 

The diagnosis is rendered facile by the coexistence of the disease 
with a dermatitis of the face. 

The treatment is largely that of eczematous conjunctivitis. 

Pemphigus. — The symptoms of pemphigus develop upon the con- 
junctival membrane as upon the skin proper. The lesions are first 
grayish spots, which as they progress become denuded of epithelium 
and leave cicatricial tissue behind. As the spots multiply, the con- 
junctiva becomes whitish, cloudy, and contracted; trichiasis may re- 
sult as the distortion of the lids follows. The excretory ducts of the 
lachrymal gland often participate in the process; the cornea eventu- 
ally becomes involved; ulceration may follow; and in severe cases the 
lids become agglutinated to the ocular globe. Blebs rarely develop 
on account of the anatomical character of the membrane involved. 
Coincident and similar lesions of the mouth, throat, and nose usu- 
ally occur. The course of the disease is commonly slow. 

Lupus Vulgaris may traverse the border of the lid and affect the 
conjunctival membrane, an ulcer developing in this region much 
more speedily than upon the skin. Tubercle bacilli have been recog- 
nized in the granulation tissue at the base of such ulcers. 

Epithelioma of the conjunctiva occurs as a flat, non-pigmented ses- 
sile tumor, at first seated upon the superficial layers of the conjunc- 
tiva ; later extending and ulcerating. It may occur as one of a group 
of superficial epitheliomata of the face. 

Lesions of this character in childhood commonly arise in connec- 
tion with xeroderma pigmentosum. 

Hydroa Puerorum. — In children with skins sensitive to the direct 



DISOBDEBS OF CONJUNCTIVA AND EYELIDS. 1083 

action of the sun's rays upon the surface, we have seen the blebs of 
hydroa puerorum develop as well upon the conjunctiva and cornea 
as upon the skin of the ears and face. The simpler soothing lotions 
with exclusion of the light have been successful in giving relief. 

Herpes Simplex and Herpes Zoster. — In some of the herpetic affec- 
tions described under these titles, the external surface of the eye 
participates in the cutaneous disorder, at times with grave results 
to the organ of vision. In the simple forms of herpes, minute vesi- 
cles appear not only upon the nose, the lids, and the ears, but also 
upon the cornea. Like the cutaneous lesions, they are frequently 
grouped, are usually short-lived, and after rupture leave superficial 
abrasions, with faint opacity of the floor. In severe cases the ulcera- 
tions of this cornea are grave. 

Zoster Ophthalmicus. — In this disease the symptoms are similar, 
but often of much more severe type, the pains, as in zona of the skin, 
persisting after the rupture of the vesicles, the parenchyma of the 
cornea becoming cloudy, a deep keratitis resulting. In most well- 
marked cases of this disorder, the tumefaction of the lids at the height 
of the process renders examination of the cornea especially difficult. 

Other diseases, such as herpes iris, dermatitis herpetiformis, ich- 
thyosis, and syphilis occur with lesions upon the skin and conjunctival 
complications. Chancres of the conjunctival membrane are exceed- 
ingly rare. All the macular, papular and pustular syphilides of sys- 
temic disease may develop upon the external surface of the eye. 

Lepra. — There is no tissue of the ocular apparatus which may not 
be invaded by the lepra bacillus, with results ranging from the milder 
forms of conjunctivitis to the gravest panophthalmia. 

Circum-corneal, conjunctival, and scleral translucent nodules, non- 
vascular, yellowish in hue, develop not merely upon the surface, but 
invade the deeper structures of the eye, and eventually by breaking 
down lead to destruction of the entire organ. One of the conspicuous 
features of most leproseries is the large number of totally blind in- 
mates. For full details of lepra as it affects this region, the reader 
is referred to the masterly treatise on this subject by Lie of Bergen. 1 

Blastomycosis. — Pusey, Carpenter, Hosmer and Smith 2 describe 
peculiar blastomycoid conditions encountered in two cases of parasitic 
conjunctivitis. The lesions upon the conjunctiva were papillomatous 
growths several millimetres in diameter, slightly tongue-shaped, 
rounded, softish, moderately red, and occurring in the lower inner 
conjunctival cul-de-sac. The organisms depicted strongly resemble 
those first recognized in California in the cases described by Eixford 
and Gilchrist. 

1 See also: W. H. de Silva, Lepra ophthalmica in Ceylon (abstr.), Brit. Med. 
Jour., t London, 1907, ii., p. 1135. A. W. Ormond, Notes on two cases of leprosy- 
affecting the eyes, Practitioner, London, 1907, Ixxix., pp. 245-251, 2 pi. (more 
recently published). 

2 Univ. of Penn. Med. Bull., 1908, Nov., xxi., 9, 6 cuts. 



1084 DISEASES OF THE MUCOUS MEMBEANES. 



DISORDERS OF THE EXTERNAL AUDITORY MEATUS. 

Furuncles of the External Auditory Meatus are not an infrequent 
accompaniment of similar lesions in the skin especially about the ear, 
though often resulting from direct infection of the hair pouches. 
In severe cases the condition may be differentiated from mastoiditis 
by the absence of aural discharge. The treatment of the furuncle is, 
first, by soothing applications (ichthyol salves or carbolated and 
opiated lotions), and eventually by incision of the suppurating focus. 

Syphilitic lesions of the external meatus are rare, and usually due 
to infection by contaminated media. The more common of luetic 
lesions in this region are condylomata, developing as verrucoid, gray- 
ish or whitish growths, interfering with the permeability of the canal 
and giving rise to a fetid discharge, tinnitus aurium, deafness, and 
pain. The local treatment is by insufflations of finely levigated calo- 
mel, which may be well mixed at times with boric acid and talc. 
The systemic treatment of the disease is of chief value. 

Otomycosis {Myringomycosis ; Fungoid Otitis Externa). — In al- 
most all cases of invasion of the auditory canal by vegetable parasites 
a septic discharge has prepared the way for the invasion. When the 
aspergillus niger, or flavus, or fumigatus invades the canal, the walls 
and fundus are usually either blackened as though coated with fine 
coal dust, or with the flavus form, have a yellowish aspect, suggesting 
that il has been dusted with iodoform or the pollen of certain plants 
(Barnhill and Wales). The dichotomously dividing mycelium with 
beaded ends is readily recognized under the microscope, the interlac- 
ing fibers entrapping in their' loops the epithelial cells. The under- 
lying surface is left eroded and hemorrhagic when the mass of vege- 
tation is scraped or pulled away. 

Examination of the debris removed from the ear reveals the inter- 
laced hyphae of the vegetation with spores and occasional flower-like 
masses which constitute the sporangium of the fruit-capsule of the 
aspergillus, this last containing the receptaculum and radiating sterig- 
mata bearing the conidia. Diffuse inflammation, otorrhea, and ec- 
zema of the part may result. There is usually some deafness, with 
a sensation of ringing in the ears, and at times a thin serous discharge 
from the external auditory meatus. Lowenberg recommends for the 
destruction of the mould the injection of dilute alcohol into the canal 
and the subsequent insufflation of boric acid in powder. 

DISORDERS OF THE NASAL CAVITIES. 

Syphilis. — Initial lesions of the mucous lining of the nose are 
exceedingly rare. The nares are most commonly involved in the in- 
herited form of the disease, where the passages are blocked by the mu- 
cous secretions from the involved membrane. In this condition mu- 
cous patches are rare, the essential condition being a gummatous 
infiltration of the membrane. In extreme cases severe ulceration fol- 



DISOEDEES OF THE NASAL CAVITIES. 1055 

lows, with destruction of bone and mutilation. Infants affected with 
this disorder are commonly supposed to be suffering from "snuffles." 
The nostrils and upper lip are frequently excoriated by the muco-pur- 
ulent secretion from the nares. In adults gummatous processes often 
result in perforation of the septum. 

Tuberculosis. — Lupus of the nostrils is a more common affection 
than is generally believed, and is characterized by the development 
upon the mucous membrane of minute nodules similar to those occur- 
ring in lupus vulgaris. When these break down and ulcerate, exten- 
sive losses of tissue (mucous membrane, cartilage, bone) occur. 
Rarely perforation of the septum results, as in syphilis. 

The process is exceedingly chronic and when not checked by mod- 
ern methods of treatment may develop to the point of producing ex- 
tensive mutilation and disfigurement. 

Rhine-scleroma. — The lesions of this rare disorder occur chiefly 
about the nostrils and upper lip, as described in the chapter in this 
treatise devoted to that disease. In some cases the mucous membrane 
is extensively involved, the lesions at first being firm, somewhat red- 
dish nodules which develop very slowly and later involve the ala? of the 
nose and the septum. In severe cases the throat, larynx, and trachea 
are involved. 

Glanders. — This contagious disorder involves very frequently the 
nasal mucous membrane, its onset being accompanied by the forma- 
tion of nodules which rapidly become pustular and finally ulcerate, 
furnishing thus a muco-purulent and offensive discharge from the 
nostrils. The lesions at first are papules, seated on a reddened and 
swollen base, which rapidly burst, become crusted, and develop into 
deep ulcers which extend rapidly. The larynx and throat as well 
as the mouth are usually involved. The accompanying systemic 
condition is usually well marked, including chills, fever, and the de- 
velopment of scarlet- to purplish-red erythema spreading over the 
nose and face, from which spring vesicles which burst and discharge. 
The disease is produced by the bacillus mallei. 

Lepra. — Dr. Morrow, of New York, believes that many cases of 
leprosy are transmitted from one individual to another by the medium 
of the nasal passages. In many cases the mucous membrane lining 
the nose is infiltrated with lepromatous growths which, as on the mu- 
cous surfaces of the eyes and the mouth, slowly degenerate, ulcerate, 
and produce an offensive discharge. The cartilage often breaks 
down ; the tip of the organ becomes depressed, somewhat as in lupus 
vulgaris, and the resulting ulceration in severe cases extends over the 
mucous membrane of the mouth, tongue, pharynx, glottis, and the epi- 
glottis. The changes are similar to those recognized in lepra of the 
eye and the mouth. 



1086 DISEASES OF THE MUCOUS MEMBEANES. 



DISORDERS OF THE MUCOUS MEMBRANE OF THE MOUTH. 
FORDYCE'S DISEASE. 

(Pseudo-Colloid of the Lips.) 

This is a chronic disorder limited to the mucous membranes of 
the lips and oral cavity, characterized by discrete, yellowish or light- 
colored, milium-like lesions unaccompanied by subjective sensation. 

The first case was described by Fordyce, 1 in 1896, at which time, 
and for a brief time after, it was thought to be rare, but subsequent 
observation has demonstrated that it is relatively common. It is more 
frequently detected on examination for other lesions, as patients rarely 
apply for its relief, owing to the insignificant subjective sensations. 

Symptoms. — The lesions are situated most frequently on the upper 
lip, lower lip, and on the oral mucous membrane extending along the 
line of the teeth as far as the last molar. They may be few or abun- 
dant, at times forming a band by aggregation of individual lesions. 
They vary in color from a yellowish hue on the lips to a whitish 
shade inside the mouth. They are primarily maculo-papules and are 
best seen by putting the mucous membrane on the stretch. 

Etiology and Pathology. — White, 2 in 70 per cent, of sixty-five 
cases, found these lesions in association with other disorders of the se- 
baceous glands, such as acne, rosacea, seborrho'ic dermatitis, and alo- 
pecia furfuracea. The same proportion of these patients suffered from 
dyspepsia. The disease develops more frequently in males than fe- 
males and most commonly between the ages of twenty and forty years 
though it occurs both before and after these periods. Fordyce origi- 
nally attributed the condition to a granular degeneration of the rete 
cells. White confirmed this. Other observers found hypertrophy of 
the sebaceous glands a conspicuous feature. 

Treatment, is usually not required, and when instituted is of little 
avail. 

Prognosis. — The disease is persistent, though benign in nature 
and productive of little discomfort or inconvenience. 

PERLECHES 

(Fr., Pour lecher, to pass the tongue over the lips, to lick.) 

(Labialitis; Beidou; Poissoxxade; Xiarde.) 

Under this title, Lemaistre and others have described a contagious 
disease of the lips recognized in many cases in children and also 

1 Fordyce. A peculiar affection of the mucous membrane of the lips and oral 
cavity, J. C. D., 1896, xiv., p. 413. 

2 White. C. J.. Fordyce 's Disease, J. C. D., 1905, xxiii., 97. (A review of 
the literature, with discussion and report of a clinical study of sixty-five cases, 
with histopathology of one case.) 

Literature: Lemaistre, Le Progres Med., 1884, 1885, November. Jaja, Giorn. 
Ital. d. Mai. ven., 1887. Morretti, Eiv. Clin. d. Bologna, 1886; Eavmond, Bull, de 
la Soc. de Derm, et de Syph., 1893, p. 289. Planche, These de Paris, 1897. 
Jacquet. Le Prat. Derm.. 1902, iii., p. 839; Annales, 1902, s. iv., iii., p. 29. Beureau 
et Fortineau, Presse Med., 1902, Gaz. Hebd. med. et chir., 1901, Oct.; Svestre and 
Gastou, Soc. des Hop., 1891. 



PLATE LVII 







k "*kft*v s^PTr ^+t*^m ■f^rvffc-. *rr*^?t^^ '*»-?■ .^«»r *-^*%- ?« 




v ^^^8Blfe>r^^ ,v 




Fordyce's Disease. (C. J. White.) 

Fig. 1. (Section.) Low power. Showing on the left the sebaceous structures, lying for the most part 
under the epidermis covered by torn skin. On the right appears the disease proper, consisting of a greatly 
hypertrophied epidermis. 

Fig. 2. (Section.) High power. Illustrating in detail the points described in Fig. 1. On the extreme 
left can be seen the granular and horny layers of the torn skin over the sebaceous glands. Adjoining this area 
can be seen the parakeratotic process beginning. Farther toward the right can be seen the hypertrophied epi- 
dermis ; the somewhat abnormal palisade layer with its infiltrating cells ; the cedematous, poorly staining 
rete cells ; the highly swollen reticulated cells; the superficial parakeratotic cells ; and lastly, the widely dilated 
lymphvessels and bloodvessels of the corium. / 



CHEILITIS. 10H7 

occasionally in adnlts. The disease is unquestionably contagions and 
transmitted, either directly or by media brought in contact with the 
lips, for example, by the use of cups in common. 

Symptoms. — In this disorder the labial commissures are symmetri- 
cally involved, the epithelium in the infected subjects being produced 
in excess, folded somewhat upon itself, and presenting a whitish or 
macerated aspect as the result of which the mucous surface of the 
lip is readily denuded. The disease not rarely spreads from the lips 
to parts in the vicinity which, in that event, present the appearance 
of a whitish pellicle, projected and folded, passing from the corner 
of the lips outward. 

Beneath the pellicle thus formed, the surface is somewhat red- 
dened and when irritated bleeds. The parts are rarely painful, 
though there is a moderate amount of itching, which leads the young 
subjects of the disorder to thrust the tongue from the mouth and in 
this way to moisten the affected region. In a few cases the parts are 
painful, wide opening of the lips producing fissures of the commis- 
sures and some pain. 

According to Jacquet, there is frequently an incidental coryza or 
diphtheroid stomatitis. In some cases the disease coexists with alo- 
pecia areata of dental origin. The disorder is short-lived, yielding 
readily under proper treatment, leaving in many cases for weeks a 
white polished surface which only slowly recovers its natural tint. 

Diagnosis. — The recognition of the disease is facile considering 
its location and its symmetry, its acute form, the absence of inflamma- 
tion, and of the symptoms of labial herpes and eczema. Care should 
be taken to avoid its confusion with syphilis of the commissures of 
the lips. 

Etiology and Pathology. — Lemaistre discovered a streptococcus 
which he called streptococcus plicatilis, isolated in some cases, and 
also found upon utensils employed by those who suffer from the 
disease. Raymond, Planche, and others, however, have recognized 
in these cases a staphylococcus albus and a staphylococcus aureus. 
The disease is evidently one of uncleanliness, propagated chiefly 
among children of the poor, and is best treated by such prophylaxis 
as is based upon proper hygiene. 

Treatment. — Weak solutions of nitrate of silver, of the sulphate 
of copper, of alum, and of bichloride of mercury are all efficient, care 
being taken that these medicaments are not swallowed by the child. 
Medicated tampons are sometimes required for local treatment of the 
fissures and angry commissures of the lips. Weak white precipitate 
ointments are available when the patient is practically relieved by 
the other remedies named. 

CHEILITIS. 

A group of disorders, possibly of similar origin and character, 
have been described under different titles, in connection with inflam- 
matory disorders of the lips. Among these may be named : 



1088 DISEASES OF THE MUCOUS MEMBBANES. 

Cheilitis Glandularis {Cheilitis glandularis apostematosa [Volk- 
man] ; Infective follicularis ; Cheilitis exfoliativa; Psoriasis lab- 
ialis; Myxadenitis labialisj Ft., Pityriasis des levres; eczema exfo- 
Uant des levres.) 

In the disease recognized by several authors under these titles, 
the lower lip is most commonly involved, chiefly the mucous face, 
but also the contiguous integumentary structures. The lip becomes 
tumid and tense, at times painful, and is studded with pin-point to 
hemp-seed-sized elevations, representing the muciparous glands, with 
dilated follicular orifices, often admitting for some distance a fine 
probe, from which exudes a thin, mucoid, or muco-purulent fluid — at 
times a clear thin serum. The crusting may be well-marked, the lips 
becoming agglutinated during the hours of sleep, and also when long 
at rest in the hours of the day. In some cases scaling occurs. Ravitch 
likens the symptoms in one of his cases to those occurring in Paget's 
disease of the nipple. In one of our cases we recognized the presence 
of a vegetable organism resembling oidium. Heidingsfeld believes 
the parasitology of the disease is accidental. 

AVe have treated several patients thus affected and have had satis- 
factory results from radiotherapy cautiously employed. This method 
has been employed with success also by Ravitch. Local asepsis is 
essential. Nearly a score of cases have been reported in literature. 1 

" Bael's Disease " (Unna) 2 is a condition in which occurs an 
indolent swelling of the glands and periglandular tissues of the lip, 
supposed to be due to a special infection, the process ending with 
some scarring at the involved points. 

"A peculiar eczematoid eruption upon the lips" is described by 
Stelwagon 3 beginning on the vermillion border, with slight irritation 
ami scaling, unaccompanied by itching. The disorder is chronic in 
course, and often limited to the vermilion border of the lips, occa- 
sionally spreading to the skin of the adjacent parts. The morbid 
process does not result in destructive degeneration or scarring. The 
tongue has been similarly involved. 

LEUCOKERATOSIS BUCCALIS.^ 

(Leucoplasia, Leucoma, Psoriasis Linguje, Smokers' Patches 
of the Mouth, Buccal Psoriasis, Ichthyosis Ltxguje, Ty- 
losis Lingu.e, Leucoplakia Buccalis. Fr., Leucoplasie, 
Plaques Blanches de la Bouche.) 

In the year 1868 Bazin described with tolerable accuracy the sev- 
eral conditions indicated by the names given above ; and since that 
date the subject has been enriched by a literature contributed by De- 

1 Volkmann, Virchow's Arch., 1870, p. 142; Purdon, B. J. D., 1893, v., p. 23; 
Gallowav, B. J. D., 1895, vii., p. 113; Eavitch, J. A. M. A., 1908, li., p. 1685. 
*Monatshft., 1890, xi., 317; Broes v. Dort., Derm. Zeitscbft., 1895, iii., p. 328. 

3 J. C. D., 1904, xxii., p. 351. 

4 For full bibliography see Benard, La Pratique Dermatologique, ii., p. 999, and 
Butlin, Diesases of the Tongue, London, 1900. 



PLATE LVIII 





Congenital Hypertrophy of Leucoplakia of Tongue. 

Tongue. 





Leueoplasie Striae of Epitheliomatous Trans- 

Tongue, formation of Leueoplasie 

Lesions of Tonque. 



LEUCOKERATOSIS BUCCALIS. L089 

bove, Kaposi, Sigmund, Plumbe, Mauriac, Schwimmer, Ingals, and 
others. 

Symptoms. — The disease is manifested chiefly in the mouth, but 
also in other mucous cavities, at the outset by some weeks or months 
of special sensitiveness to irritation produced by ingesta ; later, by 
the occurrence on the inner faces of the lips and cheeks, and on the 
dorsum and edges of the tongue, of sharply outlined, dull-whitish, 
slate-colored, or silver-whitish points, disks, streaks, bands, ribbons, 
or patches of an irregular shape, either flattened or slightly elevated 
above the general level of the mucous surface. The aspect of the 
lesions often suggests that they have been lightly penciled with the 
nitrate of silver. The disease may occur in isolated points or in pin- 
head-sized nodules, discrete or confluent, and in cases grouped, the 
grouping being often in linear arrangements, following the lines in- 
dicated by the streaks or the striae of similar composition. 

The sites of election of these lesions are : the inner face of the 
cheek in a line following that traced by the conjunction of the teeth 
of the upper and lower jaw when approximated; the gums above the 
upper canine teeth and lateral incisors ; the sulcus beside the upper 
and lower gums in the roof and floor of the mouth ; the dorsum and 
edges of the tongue, where the arrangement is usually in lines along 
the longitudinal axis ; and more rarely other parts such as the vaginal 
and other mucous membranes which have been involved. 

When closely examined these lesions are found to be made up of a 
hyperkeratinized epithelium, being covered by an adherent and more 
or less dense pellicle, removable only by artificial measures and closely 
applied to the inferior stratum of the mucosa. The lesions are rough 
to the touch, both to the finger of the physician and to the tongue of 
the subjects of the disease, but are, as a rule, not painful, though at 
times annoying by producing a certain degree of stiffness and immo- 
bility of the parts affected. At times the membrane in the vicinity 
is reddened and tender. In other cases projecting, thick, rough no- 
dules develop or a dense, well-defined elevated plaque. 

These lesions are extremely chronic of evolution, requiring months 
and often years for their full development, and resisting in a remark- 
able way the action of topical medicaments. They may be removed 
without recurrence ; or may recur after complete and radical ablation. 
If unmolested and not undergoing resolution (a termination some- 
what doubtful of occurrence), they usually, by reason of increased 
density, crack or fissure at one or another point, the fissure extending 
to the derma and arousing a local inflammatory process with the pro- 
duction of pain and distress. 'The surface is then prone to exfoliate 
and ulcerate, and epithelioma of the mouth may result. 

The proportion of the benign cases to those which result in epithe- 
lioma is not determined. Every leucokeratosis, however, may prove 
the initial stage of epithelioma, and the treatment of the former is, 
therefore, a matter of no little consequence. Leucokeratosis is prone 
to develop fissures and in cases where the patches are thickened or ver- 

69 



1090 DISEASES OF THE MUCOUS MEMBBANES. 

rucous, epithelioma often results. The cases which develop in syph- 
ilis cannot be distinguished clinically from others. They are classi- 
fied by Fournier as para-syphilitic lesions, and are rebellious to treat- 
ment. 

Etiology. — The cause of these cases is suggested by some of the 
names given above. The disorder occurs almost exclusively in the 
mouth of men, and usually after middle life. Unquestionably, the 
irritation produced by tobacco, whether used in smoking or chewing, 
and the influence of carious teeth or those with sharp edges after 
fracture irritating the edge of the tongue, are all important. We 
have, however, observed typical lesions in the mouth of men who 
had never contracted syphilis nor used tobacco. The resemblance of 
these lesions to the mucous patches of syphilis is obvious; and it is 
believed that syphilis, when not actively efficient in the production of 
leucokeratosis buccalis, may be one of its indirect causes. It is, how- 
ever, important to note that all symptoms here described occur in 
persons who have never suffered from syphilis; and such symptoms 
are in the latter class as intractable as in others. 

Pathology. — It is not definitely known if the primary change is 
a pure hyperkeratinization of the epithelium or an inflammatory proc- 
ess of the papillary layer. The horny layer is hypertrophied, the 
cells retaining their nuclei. In the derma there is always more or 
less inflammatory infiltration, and often the papillae are partially ob- 
literated. Fordyce states that the overgrowth and proliferation of 
the interpapillary processes are exceptional. Leloir insists that the 
epitheliomatous process always begins, not at the level of the hyper- 
keratosis of the mucous membrane, but below the fissure or other 
lesion induced by the induration of the plaque or streak, indicating, 
in other words, that the epitheliomatous change is rather an accident 
than an essential part of the process. 

Diagnosis. — The diagnosis is chiefly from syphilitic lesions of the 
mouth, which should be recognized, as a rule, by their softness and 
tendency to ulcerate, as well by their situation, which is far less dis- 
tinctive than in the case of leucokeratosis of the mouth. A history 
of infection and of symptoms of the disease in other regions of the 
body would usually indicate the nature of the process. 

The only malady likely to be confounded with leucokeratosis of 
the mouth is lichen planus ; and it is important to note that some 
confusion exists on this point in several descriptions of the two dis- 



In lichen planus of the mouth there may be recognized over 
the tongue, the palate, and other parts, dense, smooth or fissured 
plaques, rings, festoons, linear stria?, or disks covered by a silver-whit- 
ish pellicle. It is clear that the distinction between these and leu- 
cokeratosic lesions is in a high degree obscure, and for the present the 
most that can be done is to search with special care for other symp- 
toms of the disease upon the cutaneous surfaces of the body pointing 
to either lichen planus or to syphilis. 



LEUCOEEEATOSIS BU CCA LIS. 1091 

Treatment. — The treatment of leucokeratosis of the mouth is firsl 
by abstention from all local irritants (tobacco; highly spiced, healed, 
acetous, and iced articles of food and drink), by the care of the 
teeth, and by the employment of soothing sprays or lotions containing 
potassium chlorate, boric acid, balsam of Peru, iodized phenol, myrrh, 
or muriated iron. The most of the cases whether pre-epitheliomatoue 
or of milder type have been successfully treated by us with radio- 
therapy; but advanced epithelioma, even though associated with 
leucokeratosis, commonly requires surgical ablation. In employing 
the :r-ray in the mouth, the sound parts are carefully protected by ray- 
proof tubes. 

Silver-nitrate may be applied to any ulcerated or fissured points, 
both in solution and by sweeping the solid crayon over the surface. 
The French make use of the salicylates in the same way. 

Destruction or removal of the lesions may be secured by the em- 
ployment of caustics, chemical or galvano-cauteric ; by erasion with 
a curette; or by surgical ablation. When practicable, the burr of the 
dental engine may be used after injection of cocaine muriate. Where 
the patches are not too dense and extensive, this has generally been 
productive of good results. Vidal employed a twenty per cent, solu- 
tion of chromic acid. 

Sherwell reports complete removal of the patches by the use of 
undiluted liquor hydrargyri nitratis. The mouth is stuffed with 
cotton to protect adjacent parts; the solution is applied and allowed 
to remain from fifteen to twenty minutes, after which it is neutral- 
ized with sodium bicarbonate. If necessary, the application may be 
repeated two or three times at intervals. 

Pierce was successful in one case after rubbing into the patches 
pyoktanin-blue, followed immediately with an aqueous solution of 
anilin-oil. The applications were made daily for three months. 

For leucokeratosis of the vulvo-anal region complete excision has 
given the best results. 

Prognosis. — The prognosis is fairly favorable in the case of all 
subjects of the disease who consent to deny themselves absolutely the 
luxury of tobacco-usage in every form, and who can follow a pre- 
scribed hygienic and medicinal course. For all others there is dan- 
ger of epithelioma. 

Variola- — Preceding the appearance of the skin manifestations of 
variola, intensely red, discrete maculo-papules may be seen upon 
the mucous' membrane of the tongue, cheeks, palate, and pharynx. 
Owing to moisture and the delicate structure of the mucous mem- 
brane, these lesions, instead of passing through the vesicular and 
pustular stage, rapidly become superficial erosions or ulcerations, 
often covered with a whitish or grayish pultaceous pellicle. In num- 
ber the mouth-lesions are less conspicuous than those of the skin; 
they are most numerous in the pharynx and upon the dorsum of the 
tongue ; and may lead to great swelling of that organ (glossitis 
variolosa) and to extreme pain in deglutition. 



1092 DISEASES OF THE MUCOUS MEMBRANES. 

Vaccinia. — Vaccinal lesions within the mouth through autoinocu- 
lation, while possible, are very rare. A case is reported of a woman 
who inoculated her tongue by sucking the virus from her infant's arm. 

Scarlatina. — In this disease, shortly after the onset of general 
symptoms and before the appearance of the skin-eruptions, the 
fauces, palate, and tonsils present a deep-red coloration which later 
becomes somewhat punctate. Some swelling and cedema of the mu- 
cous membrane develop. The tongue is seen to be heavily coated 
with a white fur ; this coating is first lost at the apices of the swollen 
papillae, giving an appearance of bright red puncta scattered over a 
white background. Later the extra coat is exfoliated leaving the 
tongue intensely red and uneven by reason of the swollen papillae — the 
so-called " strawberry tongue." 

Measles. — Koplik's spots which are believed to be diagnostic of 
rubeola occur on the mucous membrane of the palate, uvula, lips, and 
cheeks; and consist of irregular bright-red, pinhead to split-pea-sized 
areas in the center of each of which is situated a bluish-white punc- 
tum. These macules precede the cutaneous exanthem often as long 
as seventy-two hours. 

Erythema Multiforme. — The upper and lower lips, inner faces of 
the cheeks, the gums, the soft and hard palate, and at times, the pha- 
rynx, exhibit the lesions of multiform erythema, occurring in the 
form of vesicles, hyperaemic macules, papules, and even blebs with 
serous or sero-pustular contents. The lesions begin as pin-point to 
large seed-sized, isolated, deeply tinted elevations. 

In severe cases, painful erosions form. The parts then become 
tender and swollen ; and when hemorrhagic erosions form, there may 
be ulceration of a superficial character. Similar lesions occur upon 
other mucous tracts (genital and facial). The patients are usually 
in middle life. 1 

Psoriasis is a disorder affecting the skin in such a large propor- 
tion of dermatoses with accidental concurrence of lesions in regions 
of the body outside of the skin, that it is not surprising to find buccal 
and other phenomena coexisting with psoriasis of the skin. Derma- 
tologists in general refuse to accept the fact of a true psoriasis of the 
mucous surfaces. Oppenheim 2 recognized the occurrence of multi- 
ple, round or oval shaped, well defined, bluish white plaques on the 
mucous surface of the cheeks and hard palate which when histologic- 
ally examined, were recognized as the seat of a parakeratosis, with 
hyperkeratosis of the epithelium and inflammation of the papillary 
body. Elei'din and keratohyalin were absent ; there were no sclerotic 
changes in the connective tissue of the bloodvessels. 

Herpes Zoster may affect, with characteristic lesions, one side of 
the throat, cheeks, and gums, when the branches of the superior max- 

1 Cf. Caspary, Archiv, 1893, xxvi., 1; Eppinger, V. Cong. d. Deutsch. Derm. 
Gesellschft., 1895, p. 83 ; Kaposi, ibid., 1895, p. 13 ; Neumann, Vierteljahr. f . Derm., 
1886 ; Kosenthal, V. Cong. d. Derm. Gesellschft., 1895, p. 34, and V. Cong. d. Derm. 
Gesellschft., p. 556. 

2 Monatsh., 1903, xxxvii., p. 490. 



DISORDERS OF THE MUCOUS MEMBRANES OF THE MOUTH. 1093 

illary are involved. There is usually coincident pain, dysphagia, and 
toothache. When the third branch of the trigeminus is involved, the 
side of the tongue may exhibit characteristic features. After re- 
moval of the crusts painful erosions may form. 

The diagnosis is between the more common forms of neuralgia of 
the same region and herpetiform disease in general. 1 

Pseudo-Herpes Buccalis (Stomato-pharyngitis herpetica; Fr., 
Angine couenneuse commune; Anglne vesiculeuse; Herpes du 
Pharynx) . 

In the several conditions described under these titles, vesicles 
form on the mucous surface of the mouth, pharynx, and larynx, her- 
petiform in character. These lesions are pin-point to hemp-seed 
sized vesicles, surmounting a reddened base, often grouped, and when 
irritated producing erosions after bursting. There may be coincident 
tumefaction of the uvula, soft palate, larynx, and base of the tongue, 
often productive of much dysphagia. The disease usually concludes 
its career in from ten days to a fortnight. It has occurred in con- 
nection with tuberculin injections, the use of antipyrin internally, 
tobacco-usage (especially by smoking), icterus, malaria, pneumonia, 
erythema multiforme, and influenza. 

The treatment is by proper dietetic precautions and soothing 
mouth-washes, when the special indications in each case have been 
met. 2 

Angioneurotic (Edema and Urticaria. — In these conditions the mu- 
cous membrane of the mouth may be slightly or very severely impli- 
cated. In mild cases, swellings like those of the wheal develop over 
the mucous membrane of the mouth, pharynx, and epiglottis. In 
severe cases the tongue may become so swollen as to project from the 
mouth and require blood-letting for its reduction. In yet other cases 
suffocation is threatened by enormous blood-red swelling of the epi- 
glottis and pharynx. The causes are described under the general 
title of these diseases. Drug-idiosyncrasies, and the ingestion of 
shell-fish and of other special articles of food, such as the smaller ber- 
ries with seeds, are responsible for some cases. 3 

Leukaemia. — In acute lymphatic leukaemia, hemorrhages, petechial 
and diffuse, and areas of ulceration and necrosis are frequently noted 
involving the mucous membrane of the mouth and nose. In chronic 
lymphatic leukaemia, lymphomatous nodules and tumors occur in these 
situations as well as on the skin. 

Xanthoma. — Butlin describes a case of xanthoma ("xanthe- 
lasma") with eye-lid and conjunctival lesions, and characteristic 
patches on the palms, elbows, and knees, in which whitish, oblong, 
elevated plaques occurred on the sides of the tongue. Microscopical 
examination revealed a condition similar to that recognized in cuta- 

1 See Kaposi, Path. u. d. Hautkrankht, Wien, 1893, also Kraus, Die Erkrank. 
d. Mundhohle, Nothnagel's Encye. Wien., 1902, xvi., p. 163. 

2 Brokhart, Monatsh., 1885, p. 164. 

3 Cf. Kaposi, Hautkrankheiten, 3d ed., p. 324; also Melton, Vierteljahr. f. 
Derm. u. syph., 1877, p. 173. 



1094 



DISEASES OF THE MUCOUS MEMBRANES. 



neous lesions of the same character. 1 Rhodes 2 reports the finding of 
thickly set nodules in the vestibule of the larynx occurring in a pa- 
tient suffering with generalized xanthoma. Histological examina- 
tions of these growths demonstrated their character. 

Adenoma Sebaceum (" Pringles Disease" ). — In February of 
190-i, Buschke 3 demonstrated the case of a lad thirteen years of age 
with lesions of adenoma sebaceum over the face and similar lesions 
in the mouth in association with telangiectases of the same part. 

Lupus Vulgaris may produce nodules of granulation tissue in the 
mucous membrane of the mouth as well as the nose. The gums and 
soft and hard palate may become dull reddish in hue, spongy, eroded, 
ulcerated, or after repair become the seat of cicatrix. 

Scherber 4 calls attention to the value of hydrogen peroxide painted 
over ulcers in full strength, and used as a mouth wash diluted. He 
suggests its value indicates that the germs concerned are anaerobic. 
Lichen Planus.- — The lesions of lichen planus upon the mucous sur- 
faces, heretofore described in connection with that disease as it occurs 
upon the skin, are, it has been asserted, more common in the mouth 

than is generally believed. As dis- 
tinguished from other lesions of the 
same locality, the individual elements 
of the eruption are often recognized 
as isolated and irregularly distributed 
or grouped and linear, softish, pin- 
h< ad-sized and somewhat larger, flat- 
fish papules covered with whitish 
mucus. When this last is removed, 
the eruptive elements do not greatly 
differ from those displayed in lichen 
planus of the skin. 

Lupus Erythematosus. — The patches 
of lupus erythematosus occurring on 
the mucous membranes differ greatly 
from the lesions of the same disease 
upon the skin ; and their exact nature 
has been questioned. Trautmann in 
thirty published cases finds the lips 
involved in forty-three per cent., the 
mucous membranes of the cheek in 
forty per cent., the palate in thirty- 
three per cent., and other parts of the 
oral cavity in a similar percentage. 

The patches are vividly red in color with depressed centers. 
Disseminated pearly-gray macules indicate the beginning of atrophy. 

1 Cf. Butlin, Treat, on the Tongue, p. 331. 

2 A case of Xanthoma Multiplex, with interesting throat complications, Laryn- 
goscope, October 19, 1906, and Chi. Med. Becorder, May, 1908. 

3 Monatshft., 1904, xxxviii., p. 32. 

* Deutsch. med. Wochenschr., 1907, p. 28. 




Lichen planus of the mucous surface 
of the tongue. 



LEUCOEEBATOSIS BUCCALIS. 



1095 



The lips are not rarely involved in these cases by direct extension 
from the face though we have had under observation cases in which 
the lips and circumoral regions were the chief areas of involvement. 
The lips are often swollen, dull reddish in hue, dry, and scaling, the 
patches showing a reddish areola and a thinning center, dull whitish 
in hue. Dubreuilh recognized here, as in the skin, radiating or whit- 
ish and grayish lines over the patch disappearing when atrophic 
changes occurred. Morris 1 describes a case in which the tongue 
appeared to be denuded of its epithelium, having a brilliant red color 
and smooth shining surface. Warde 2 found that ten out of fifteen 
cases suffered from either hypertrophic or atrophic rhinitis, a posi- 
tion combated by Fordyce. 

Syphilis. — The syphilitic lesions of the mucous lining of the oral 
cavity are described in this work under the title of that disease. The 
lesions include initial scleroses of the mucous or muco-cutaneous sur- 
face of the lips both within and without the vermilion border ; initial 
sclerosis of the tongue, on the inside of the cheek, the palate, and the 
tonsils ; mucous patches, scaling patches, and condylomata, chiefly 
affecting the cutaneous surface and also the muco-cutaneous surface. 

Fig. 222. 




Chancre of the lip. 

Papules and bullous lesions of the erythema group of skin diseases 
can readily be taken for mucous patches. Relapsing herpes of the 
mouth shows as gray spots with red periphery and attachment of the 
epithelium at the margin. Burning pain is characteristic and is 
absent in mucous patches. Mercurial stomatitis may produce discol- 
oration and thickening which would suggest the scars of syphilis or 

1 B. J. D., 1903, xv., p. 410. 
2 B. J. D., 1902, xiv., p. 332. 



1096 DISOBDEBS OF THE MUCOUS MEMBBAXES OF THE MOUTH. 

leucoplakia. Antipyrin and other anilin derivatives have produced 
erosions in the mouth which suggest specific changes. 

Actinomycosis of Mucous Membranes probably results from vege- 
table ingesta through the medium of the mouth, respiratory tract, 
or the skin. The disease is of insidious origin, rarely acute, more 
often sub-acute in type, characterized at first by tumefaction of the 
cheeks, tongue, or floor of the mouth, accompanied by cedema, dys- 
phagia, dyspnoea, and febrile phenomena. At times a carious tooth 
furnishes the invasium atrium. Multiple foci coalesce sooner or later, 
producing a hard firm swelling giving rise to a serous discharge. Ul- 
ceration, fistulous sinuses, perforation of the tissues affected often 
result. At times the picture presented is one of multiple, yellowish- 
white, abscess-like puncta, forming on a firm insensitive base. On the 
tongue which is most often involved, minute nodules may be recog- 
nized usually on the anterior half. 

Precancerous Keratosis of the Mucous Surfaces of the Mouth. — Pri- 
mary carcinoma of the mucous surface of the mouth occurs both as a 
sequel of leucokeratosis and also in cases where the patches of the 
disease last named have not been recognized. The change may follow 
any local irritation such as, for example, occurs in tobacco-chewers 
and smokers, and in the individual who is in the habit of chewing 
grain for testing it in commercial transactions. The parts most often 
involved are those nearest the vermilion border of the lip where a 
simple area of keratosis and scaly thickening of the part may occur, 
though the inner faces of the cheeks, the velum, and parts of the 
tongue and hard palate may be involved. 

Cancer (epithelioma) is exceedingly common on the mucous and 
muco-cutaneous surface of the lips and somewhat more rarely over the 
entire mucous tract of the mouth, tongue, inner border of the lips, etc. 
In many of these cases a distinction between syphilis and carcinoma 
is exceptionally difficult, the problem often being solved only after ex- 
cision of a portion of the morbid tissue and histological examination. 
The age of the patient and character of the growth (which differ 
greatly in different subjects), the history of the patient with respect 
to precedent lues; the tobacco habits of male patients, and the local 
treatment instituted bear upon the question of diagnosis. In a few 
of the cancerous cases, there is transformation of the syphilitic into 
the epitheliomatous process, the former beginning in early or middle 
life and the latter only after long continued irritation — in the case of 
male patients often from the use of tobacco. 

Scurvy (Scorbutus). — In addition to the cutaneous symptoms 
characteristic of scorbutus (hemorrhages into the skin and subcutan- 
eous tissue, purpuric lesions taking on a greenish hue, petechia?, ul- 
cerations with foul base, ecchymoses) striking phenomena are exhib- 
ited in the mouth. The lesions include swelling of the gums, espe- 
cially around carious teeth, the latter being often sunken beneath a 
bluish tinted fungoid growth. Ulceration, which is characteristic 
of the disease, soon follows, spreading along the margin of the gums, 



DISOBDEBS OF THE MUCOUS MEMBBANES OF TEE MOUTH. 109*3 

producing a characteristic fetor of the breath and, in severe cases, de- 
hiscence of the teeth and alveolar necrosis. 

The most commonly accepted etiology of the disease is that which 
assumes the presence of a specific toxine. The lesions in the mouth are 
to be distinguished from purpura hemorrhagia, mercurial cachexia, 
and acute lymphatic leukaemia. 

Prophylaxis is of the greatest value in treatment, including a 
proper dietary and environment. The local management of the 
lesions in the mouth is by strict asepsis and stimulation of the fun- 
goid growths about the teeth. 1 



Fig. 223. 






* 








Em3£ 




1 1 m! 


■feb 




nt; s v^ 


s*f ■ 





Blastomycosis of the lip. 

Blastomycosis. — We have had under observation one typical case 
of blastomycosis involving the mucous membrane of the lower lip 
within the vermilion border on the right side of the median line. 
The growth was of the size of a large mulberry and resembled that 
berry in the fact that it was beset here and there over the surface 
with minute projecting points. The definition of the growth was dis- 
tinct ; it was sof tish to the touch ; and occurred in the case of an adult 
patient engaged in farming, who at one time had been chewing a quan- 
tity of grain in order to test it. In another case seen by us where 
there were lesions elsewhere than on the lip, a much smaller growth 
developed on the muco-cutaneous border. 

Lepra. — In a large proportion of all cases of tubercular leprosy 
examined by us characteristic nodules have been recognized on the pos- 
terior aspect of the tongue. Similar lesions occur on other mucous 
membranes than in the mouth as also over the glottis and epiglottis 
and the trachea. In all these cases recognition of the bacilli of the 
disease is rendered facile by the abundance of these organisms not 
only in the mouth but also over the nose. 

1 Osier's Modern Medicine, vol. i., p. 897. 



1098 DISEASES OF THE MUCOUS MEMBRANES. 

DISORDERS OF THE VULVA AND VAGINA. 

Syphilis. — The common lesions of lues in this situation are the 
initial sclerosis, moist papules exhibited as mucous patches and condy- 
lomata ; gummata and ulcers, the latter being followed by atrophy and 
cicatrices. Any or all of these manifestations may occur wholly on 
the cutaneous surface, or on the mucosa, or occupy both situations. 
They may develop to an unusual degree here owing to the conditions 
favorable to their growth. This is especially true with regard to con- 
dylomata. The usual site of the initial sclerosis is the labia majora 
and minora, the vestibule, the meatus urinarius, the clitoris, the 
fourchette, the os uteri, and, rarely, the point of the superior commis- 
sure of the vulva. In these situations their transformation in situ 
to condylomata, mucous patches, and other secreting lesions of sys- 
temic disease is readily effected in consequence of the heat, moisture, 
and friction to which they are here exposed. The deformities of the 
genital region, venereal in origin, are commonly of exaggerated type 
and as a rule, in fetor, in abundance of secretion, and in volume they 
far exceed the corresponding lesions in the male sex. Inguinal aden- 
opathy is not a characteristic of genital chancres in woman. (Cf. 
chapter devoted to Syphilis.) 

Chancroid. — These lesions occur most commonly on the labia 
majora and minora, the vestibule, and the mucous membrane of the 
vagina near the ostium. Perineal chancroids are far more common 
in women than in men by reason of the readiness with which the 
auto-inoculable secretion flows over the perineum to the sensitive and 
readily eroded mucous orifice of the anus. The clinical symptoms are 
exhibited early as pustules and erosions and later as ulcers and deep 
abscesses. They may be single, but as a rule, are multiple and vary 
greatly in size. They are not indurated and are usually accompanied 
by subjective sensations varying from mild itching to severe pain. 
Rarely they are complicated by gangrene or phagedena. These 
lesions are readily auto-inoculable and by extension of the process a 
serpiginous ulcer may be formed not unlike a late luetic lesion. 
Verruca acuminata, herpetic lesions, and a more or less diffuse in- 
flammation of the skin and mucosa may occur as complications. The 
important disorders to be differentiated from chancroid are the initial 
lesion of syphilis and herpes progenitalis. 

Verruca Acuminata. — These lesions occur most commonly in 
women of low social order and among these in extreme development. 
At times the entire perineal region is occupied by a mass of such 
lesions which extend over the mucous membrane of the vagina as well 
as upon the glabrous skin. 

Pruritus Vulvae. — In this disorder changes are induced both in the 
skin and mucosa by trauma inflicted during the paroxysms of intense 
itching. The mucosa may show erosions, ulcers, thickened areas, and 
finally atrophic changes. 

Inflammations of the Vulva. — Dermatitis and inflammation of the 



DISORDERS OF THE VULVA AND VAGINA. 1099 

mucosa in varying degrees, due to decomposing secretions and acrid 
discbarges, are not uncommon. Diabetic eczema and various super- 
ficial and deep pustular infections also occur. Gangrenous inflam- 
mation (noma) is seen occasionally in cachetic individuals and, as a 
sequel to one of the exanthemata, in poorly nourished children. 

Tuberculosis Cutis Orificialis is exhibited in this region as miliary 
tubercles and superficial, ragged, ill-conditioned ulcers associated with 
internal tuberculosis of this region. Other manifestations of tuber- 
culosis with larger nodules and ulcers occasionally occur. 

Dermoid and Sebaceous Cysts are occasionally seen about the vulva, 
but the most common cystic tumor is the retention cyst of the glands 
of Bartholin. 

Urethral Caruncles are small, bright-red, vascular papillomata situ- 
ated at the entrance of the urethra and are a source of annoyance from 
smarting sensations during urination and from hemorrhage. 

Lichen Planus may involve the mucosa of this region in association 
with the disease elsewhere. The lesions are similar to those described 
on the mucous membranes. (Cf. Lichen Planus of the Mouth.) 

Pemphigus Vegetans. — Vesicles, bullae, and excoriations peculiar to 
this disorder as it affects mucous membranes occur on the vaginal 
mucosa. 

Elephantiasis. — This term is applied to a hypertrophic growth of 
the genitals due to chronic inflammatory processes affecting the parts, 
and is in no way connected with the true elephantiasis of the tropics 
which is of parasitic origin. The parts most commonly attacked are 
the clitoris, labia (minora and majora), and at times the perineum. 
Negresses furnish the greater number of the cases. The disease is 
due to obstruction of the lymphatic channels which drain the external 
genital region, the obstruction being caused by changes incident to 
chronic inflammation of the parts. One or both sides may be affected 
and the enlargement may be considerable. It is exhibited as a 
brawny, firmly indurated swelling and may be accompanied by mod- 
erate or severe pain. Syphilis is an important factor in etiology. 
The condition requires surgical measures for its relief. 

Carcinoma of the external genitals in woman is most common 
between the ages of forty-five and sixty years. Early, these new- 
growths appear as well-defined, hard, flattened, nodular masses with 
ulcerating centers and everted margins. Later, an infiltration of 
secondary nodules occurs and the disease spreads to the margin of the 
mucosa and upwards to the groins. Regional adenopathy occurs com- 
paratively early. Carcinoma of the clitoris is rare and affects usually 
patients who often are the subjects of vulvar pruritus. 

Kraurosis Vulvae is a condition of the vulva in women affecting 
particularly the labia minora, preputium clitoridis, and the vestibulum 
in which there occurs a peculiar shrinking, shrivelling, or atrophic 
change. The atrophy may be preceded by intense pruritus, burning 
sensations, or hyperesthesia. Kraurosis has been developed in pa- 
tients ranging from nineteen to seventy years. Epithelioma may 



1100 DISEASES OF THE MUCOUS MEMBRANES. 

supervene, and Perrin states that leucoplasia precedes both the krau- 
rosis and epithelioma. Extirpation surgically is indicated to prevent 
malignant transformation. 

The disorders situated on the mucosa and skin of the penis are: 
syphilis (the initial lesion, papules exhibited as mucous patches, and 
condylomata, tubercles, gummata and ulcers), chancroid, balanitis and 
balano-posthitis, inflammatory phimosis and paraphimosis, gangrene, 
verruca acuminata, herpes progenitalis, lichen planus, psoriasis, poro- 
keratosis, and epithelioma. It is only necessary here to emphasize 
the fact that epithelioma, chancre, and gummata are at times mis- 
taken one for the other, that chancre and chancroid may be coexistent, 
and that herpes progenitalis and mucous patches are at times con- 
fused. For complete description of these various disorders, the chap- 
ters devoted to their discussion should be consulted. 

Affections of the tongue, mouth, and cheeks, not in association 
with recognized dermatoses, are purposely excluded from this chapter. 
For a description of this group of disorders, some rare of occurrence 
and of indeterminate character, others more common and of recog- 
nized etiology, the reader is referred to the treatises specially devoted 
to this subject. Among these affections may be named the "geo- 
graphical tongue," the grooved, wrinkled, sulcated, cleft, and other- 
wise altered tongue usually occurring in childhood and probably due 
to congenital deformity ; the " black." hairy, or hyperkeratotic tongue, 
in which hair-like filaments usually of blackish hue become visible in 
the region anterior to the circumvallate papillae ; the ringworm-like 
patches of the tongue (pityriasis linguae, glossitis areata exfoliativa) 
in which small, grayish or reddish, circumscribed, slightly elevated 
patches appear on the dorsum of the tongue commonly benign in char- 
acter and at times certainly due to grinding of the teeth in children 
during the hours of sleep ; the papillomata of the tongue, inner faces 
of the cheeks, and lips, occurring in both sexes and at all ages ; the 
" tied tongue," angiokeratomata of the tongue, falsely so called ; the 
macroglossia of surgical authors, the odd-looking secreting papules of 
the gums, chin, and sub-mental region, due to fistulous sinuses con- 
nected with the base of carious teeth ; and the entire group of changes 
in the mouth and throat, due to the presence of adenoids. 



INDEX. 



Abrasions, 62 
Absagen, 1074 
Acanthia lectularia, 863 
Acantholysis bullosa, 412 
Acanthoma adenoides cysticum, 592 
Acanthosis, 46 

nigricans, 473 

diagnosis, 476 
etiology, 474 
pathology, 476 
prognosis, 476 
symptoms, 473 
treatment, 476 
Acare des folhcules, 846 
Acarus folliculorum, 846 

scabiei, 835, 841 
Achromia, 538, 540 
congenital, 539 
unguium, 993 
Acid, boric, 117 
Acne, 916 

diagnosis, 922 
etiology, 920 
pathology, 922 
prognosis, 930 
symptoms, 916 
treatment, 923 
artificialis, 917 
atrophica, 919, 937 
cachecticorum, 919 
cornea, 456 
frontalis, 937 
hypertrophica, 919 
indurata, 917 
keloid, 551 
keratosa, 920 
necrotica, 937 
papulosa, 916 
punctata, 916 
pustulosa, 917 
rodens, 937 
rosacea, 930 

diagnosis, 933 
etiology, 932 
pathology, 932 
prognosis, 936 
symptoms, 930 
treatment, 933 
scrofulosorum, 919 
sebacea, 885 
urticata, 920 
varioliformis, 937 



etiology, 91 
pathology, 



Acne varioliformis, symptoms, 937 
treatment, 938 

vulgaris, 916, 918 
Acne, 916 

cancro'idale, 588 

coinedon, 911 

cornde, 456, 920 

decalvante, !IS4 

keloidienne, 986 

ponctuee, 911 

rosee, 930 

s6bacee fluente, 886 
cornde, 458 

varioliforme, 576 
Acrochordon, 556 

Acrodermatitis chronica atrophicans, 
522 

perstans, 365 

pustulosa hiemalis, 412 
Acrodermites continuees, 365 
Acrodynia, 1010 

diagnosis, 1012 

etiology, 1011 

pathology, 1011 

prognosis, 1012 

symptoms, 1010 

treatment, 1012 
Acromegaly, 514 
Actinomycose, 1034 
Actinomycosis, 1034 

diagnosis, 1035 

etiology, 1036 

pathology, 1036 

prognosis, 1037 

symptoms, 1035 

treatment, 1036 
Addison's disease, 534 
Adenoma of sebaceous glands, 588 
diagnosis, 590 
etiology, 589 
malignant forms of, 589 
pathology, 589 
symptoms, 588 
treatment, 590 

sebaceum, 588, 592 
Adenomes sebacees, 588 

cancro'idaux, 588 
Adiposis dolorosa, 562 
^Estridte, 1026 
Afghan plague, 1066 
Age, 69 
Ag-nails, 997 
Ainhum, 1074 

etiology, 1076 

prognosis, 1076 

symptoms, 1075 



1101 



1102 



INDEX. 



Ainhum, treatment, 1076 
Akne, 916 
Aktinomykose, 1034 
Albinism, partial, 538 
Albinismus, 539 
etiology, 540 
symptoms, 539 
Albugo, 993 
Aleppo evil, 1066 
Alibert's keloid, 549 
Alkalies, 99 
Alopecia, 955 

diagnosis, 962 
etiology, 962 
pathology, 962 
prognosis, 966 
treatment, 963 
adnata, 955 
areata, 966 

congenital, 955 

diagnosis, 972 
etiology, 970 
pathology, 971 
prognosis, 974 
symptoms, 966 
treatment. 973 
circumscripta, 966 
congenita, 955 

etiology, 958 
pathology, 958 
prognosis, 958 
symptoms, 955 
treatment, 958 
circumscribed, 956 
ircneralized. 956 
" obstetrical." 957 
" sutural," 957 
furfuracea, 960 
neurotica, 970 
pityrodeSj capillitii, 960 
prematura, 958 
seborrhoi'ca. 960 
symptomatic, presenile, 958 
syphilitic, 660 
ungualis, 992 
Alopeeir, 955 

eicalricicllc innomince, 985 
congenitale, 955 
Alphos, 276 
Alpine scurvy, 1069 
Anaemia, 75 
Anaesthesia cutis, 766 
Anakhre. 1074 
Analgesic paralvsis with whitlow, 55 

997 
Analgesics. 101 
Anatomical tubercle, 609 
Anatomy of skin, 17 
Anderson's powder, 145 
Anetodermia erythematodes, 522 
Angiokeratoma, 470 
diagnosis, 471 
etiology. 471 
pathology, 471 
prognosis. 471 



Angiokeratoma, symptoms, 470 

treatment, 471 
Angiokeratome, 470 
Angioma, 567 

diagnosis, 569 
etiology, 569 
pathology, 569 
prognosis, 571 
symptoms, 567 
treatment, 570 
cavernosum, 568 
infective, 571 

pigmentosum et atrophicum, 593 
serpiginosum, 571 
diagnosis, 572 
etiology, 572 
pathology, 572 
symptoms, 571 
treatment, 571 
Angiome cystique. 574 
Angiomyoma, 565 
Angioneurotic oedema, 169 
symptoms, 170 
treatment, 170 
Anhidrose, 876 
Anhidrosis, 876 
Anidrosis, 876 

treatment, 876 
Animal extracts, 101 
parasites, 834 
poisons, 357 
Ankylostomiasis, 1012 
Ankylostomum Americanum, 1012 

duodenale, 1012 
Anomalies of pigmentation, 532 
diagnosis, 536 
pathology, 535 
prognosis, 538 
symptoms, 532 
1 reatment, 536 
Anonychia, 9S9 
Anophelinse, 864 
Anthemata, 65 
Ant lira robin. 118 
Anthrax, 352 

diagnosis, 354 
etiology, 353 
pathology, 354 
prognosis, 355 
symptoms. 353 
treatment, 354 
maligna, 352 
simplex. 349 
Anthrax, 349 
Antimony, 101 
Apes melliferae. 865 

Aplasie moniliforme intermittente, 949 
Area Celsi, 966 

Johnstoni, 966 
Argyria. 535 
Ami-pit itch. 1037 
Arrectores pilorum, 37 
Arsenic, 96 
Arthrodynia. 1010 
Arzneiexantheme, 259 



INDEX. 



11 OS 



Aspergillus, 1084 

flavus, 1084 

fumigatus, 1084 

niger, 1084 
Asteatosis, 904 

prognosis, 904 

symptoms, 904 

treatment, 904 
Atheroma, 907 
Atjirepsie, 502 
Atoxyl, 98 

Atrichia, congenital, universal, 955 
Atrophia cutis, 519 

maculosa cutis, 522 
et striata, 520 

pilorum propria, 946 

senilis, 519 

symptoms, 519 

treatment, 519 

Atrophic leprosy, 1050 

spots, 520 
Atrophies, 519 

neuriticum, 522 
Atrophoderma pigmentosum, 593 

striatum et maculatum, 520 
Atrophy, 77 

blanching, 523 

congenital, 521 

diffuse, idiopathic, 522 

partial, idiopathic, 520 
symptomatic, 521 
Aushohlung der Nagel, 992 
Aussatz. 1044 
Auto-infection, 70 



Bacillus acnes, 921 
Bacteria, 75 

Bacterial suspension, for injection, 
preparation, and standardization of, 
103 
" Bad disorder," 647 
Bael's disease, 1088 
Baldness, 955 
Balggeschwulst, 907 
Banko-kereude, 1074 
Barbadoes leg, 1013 
" Barber's itch," 799 
Barcoo rot, 1079 
Barkoo, 1079 
Bartfinne, 976 
Bassorin paste, 113 
Baths, 1017 

antiseptic, 108 

marine, 107 

salt, 107 

sulphur, 107 

tar, 107 
Becquerel rays, 131 
Bed-bugs, 863 
Beigel's disease, 952 
Belostoma, 851 
Bettioanze, 863 
Big-nose, 1074 



Biskra bout on. 1066 
Black fever, 443 

small-pox, 428 

tongue, 1100 
Black-head, 911 
Blaschen, 59 
Blaschen/lecte, 369 
Blasen, 61 

Blasenausschlag, 390 
Blastomycetic dermatitis, 825 
Blastomycosis, 825 

diagnosis, 832 

etiology, 828 

pathology, 829 

prognosis, 833 

symptoms, 826 

treatment, 832 
Slattern, 424 
Blebs, 61 

Bleeding stigmata, 882 
Blisters, 61 
Blood-vessels, 30 
Bloody sweat, 882 
Blue disease, 443 
Bhit gcschwiir, 345 
Boba, 1061 
Body-louse, 857 
Boif, Bucharest, 1068 
Boils, 345 
Boquet, 1010 
Boric acid, 117 
Borken, 62 
Bouba, 1061 
Bou-bou, 1010 
Bonton d'Amboine, 1061 
Bouton d'Orient, 1066 
Bowditch Island ringworm, 1037 
Brandscliwiire, 349 
" Brandy-nose," 930 
Bridou, 1086 
Bromhidrosis, 877 
Bromidrosis, 877 

etiology, 877 

pathology, 877 

treatment, 878 
Bronze diabetes, 534 
Brown-tail moth dermatitis, 851 
etiology, 852 
pathology, 852 
symptoms, 851 
treatment, 852 
Bubas, 1061 
Buccal psoriasis, 1088 
Bucharest boil, 1068 
Bucnemia tropica, 1013 
Bug, electric light, 851 

harvest, 849 
Bugs, 863 

Bulklev's alkaline solution of tar, 221 
Bullae, 61 
Bullous dermatitis, 402 

following vaccination, 441 

eruption, peculiar, 382 
Burmese ringworm, 1037 
Burns, 256 



1104 



INDEX. 



Cachexia strumipriva, 515 

Cachexie pachydermique, 515 
Calcification of skin, 587 
Calliphora erythrocephalis, 102( 

vomitoria, 1026 
Callositas, 476 

pathology, 476 
symptoms, 476 
treatment, 476 
Calvities, 955 
Calx sulphurata, 100 
Cancer, 735 

epithelial, 735 
fibrous, 742 
hard, 742 
lenticular, 742 
of connective tissue, 742 
of extremities, 748 
of genital organs, 747 
of head, 746 

of mucous membranes, 748 
scirrhous, 742 
Cancer en cuirasse. 742 
Cancroide, 549, 735 
Cancroid ulcer, 737 
Canities, 952 

etiology, 953 
pathology, 954 
symptoms, 952 
treatment, 954 
unguium, 993 
Canker-rash, 419 
Carathe, 1040 
Carbolic acid, 101, IIS 
Carbon dioxide, 132 
Carbuncle, 349 

splenic fever, 352 
Carbunculus, 349 
diagnosis, 350 
etiology, 350 
pathology, 3^ 
prognosis, 351 
symptoms, 349 
treatment, 350 
Carcinoma, clinical forms, 745 
epitheliale, 735 
melanotic, 744 
of skin, 735 

diagnosis, 752 
etiology, 749 
pathology, 750 
prognosis, 760 
symptoms, 736 
treatment, 755 
pigmented, 744 
tuberose, 744 
Carrion's disease, 1063 
Cascadoe, 1037 
Cathartics. 99 
Catiri, 1039 
Causalgia, 764 
Cells, giant, 79 
mast, 79 



plasma, 78 
Cellulome epithelial benin, 592 
Cephenomyia, 1029 
Chafing, 143 
Chalazion, 908 
Chalazodermia, 557 
Chancre, 650 

treatment of, 709 
Hunterian, 650 
indurated, 650 
non-infecting, 71o 
simple, 713 
soft, 713 
Chancre du Sahara. 1066 
Chancrelle, 713 
Chancres of nails, 1004 
Chancroid, 713 

diagnosis, 716 
pathology, 716 
prognosis, 718 
symptoms, 713 
treatment, 717 
Chappa, 1073 
Cnarbon, 352 
Cheilitis, 1087 

exfoliativa, 1088 
glandularis, 1088 

apostematosa, 1088 
Cheiropoetalgia, 1010 
Cheiro-pompholvx. 407 
Cheloid, 549 
Cheloide, 549 
Chicken-pox, 435 
"Chigger" disease, 1026 
Chignon fungus, 952 
Chigoe, 1026 
Chilblains, 142, 257 
Chinese ringworm, 1037 
Chloasma, 818 

oachectieorum, 533 
uterinum, 533 
Chloral-camphor, 120 
Chorionitis, 504 
Chromidrosis, 879 
etiology, 879 
pathology, 879 
treatment, S81 
Chrysarobin, 100, 118 
Chrysomyia macellaria, 1027 
Cicatrice, 547 
Cicatrices, 64 
Cicatricial keloid, 550 
Cicatrix, 547 

diagnosis, 548 
etiology, 548 
pathology, 548 
symptoms, 547 
treatment, 548 
hypertrophic, 550 
Cimex lectularius, 863 
diagnosis, 864 
treatment, 864 
Class I, 13o 

II. 445 

III, 451 



INDEX. 



1105 



Class IV, 5.9 

V, 531 

VI, 547 

VII, 701 

VIII, 7S1 

IX, 807 

X, 1007 
Classification, 133 

Hebra, 133 
Clastothrix, 94 , 
Clavus, 477 

histology, 477 
symptoms, 477 
treatment, 478 
Climate, 72 
Climatic bubo, 1073 

symptoms, 1074 
treatment, 1074 
Clothing, 73 
Clou, 345 

de Biskra, 10G6 
Coccidioidal infection, 833 
Cochin leg, 1013 
Coco, 1061 
Cod-liver oil, 99 
" Cold-sores," 370 
Collodion, 115 
Colloid degeneration. 80 

metamorphosis of skin. 586 
diagnosis, 587 
etiology, 5S7 
pathology. 587 
treatment, 587 
milium, 586 
Collo'idome mil in ire. 586 
Column* adiposae, 21 
Comedo, 911 

diagnosis, 914 
etiology, 912 
pathology, 912 
prognosis, 915 
symptoms, 911 
treatment, 914 
Compsomyia macellaria, 1027 
Condyloma acuminatum, 482 
Condylomata, 682 

lata, 665 
Condvlomatosis pemphigoides maligna, 

404 
Congenital fibro-sebaceous disease, 910 
Conglomerate pustular perifolliculitis, 

344 
Conjunctiva and eve-lids, disorders of. 
1081 
acne rosacea, 1082 
blastomycosis, 10S3 
demodex folliculorum, 1081 
" eezematous " conjunctivitis, 

1081 
epithelioma, 1082 
exanthemata, 1082 
herpes simplex, 1083 
hvdroa puerorum, 1082 
lepra, 1083 
lupus vulgaris, 1082 

70 



Conjunctiva and eye-lids, pemphigus. 
1082 
trichiasis, 1081 
zoster, 1083 
Consomption dartreuse, 999 
('(institutional disorders, 69 
Contagion, 74 
Copaiba, 101 
( lopper-nose, 930 
Cor, 477 
Curium, 21 

cellular structure of, 77 
degeneration in, 79 
fibrous structure of, 77 
pathological cells of, 78 
Corn, 477 
( lornification, 29 
Cornu cutaneum, 470 
etiology, 479 
pathology, 480 
prognosis, 481 
symptoms, 479 
treatment, 481 
humanum, 47!i 
( lorpuscles, Krause, 30 
Paccinian, 32 
Vater, 32 
( losme's paste, 758 
Counter-irritation, 120 
Couperose. 930 
Cow-pox, 437 
Crab cellulitis. 358 
Crab-louse, SCO 
Cracks, 63 

( Irateriform ulcer, 738 
Craw-craw, 1072 
etiology, In?.'! 
prognosis, 1073 
treatment. 1073 
Creeping eruption, 1028 
( venation degeneration, 80 
Creosote, 101 
Cretinoid oedema, 515 
Cro files, 62 
Crustse, 62 
Crusts. 62 
Crutch itch. 1037 
Culex pungens, 864 
Culicidae, 864 

Cutaneous psorospermosis. 738 
Cute. 1039 
Cuticle, 25 
Cutis, 21 

vera, 21 
Cystadenome epithelial benin, 592 
Cystic disease, sebaceous, 910 
Cysticercus cellulosae cutis, 848 

diagnosis, S4S 
Cysts, 908 

of coil-duct, 874 
Cvtorrhvctes luis, 691 



Dactylolysis spontanea, 1074 



1106 



INDEX. 



Dandruff, SS5 
Darier's disease, 45S 
Dartre, 369 

humide, 336 
Deciduous hair-shedding. 9S7 

skin, 141 
Decollement des Qngles, 992 
Decolorized ion des Ongles, 993 
Defluvium capillorum, 955 

unguium, 992 
Degeneration, colloid, 80 
crenation, SO 
fatty. SO 
mucoid, SO 
myxomatous, 80 
oedematous, 80 
Delhi boil, 1066 
Demodex folliculorum, 840 
Dengue fever, 1010 
Depilatories. 945 
Dercum's disease, 562 
Derma, 21 
Dermamyiasis linearis migrans cestosa, 

1028 
Dermatagra. 1069 
Dermatalgia, 762 
diagnosis, 763 
treatment, 762 
Dermatite, 249 

exfoliatricc. 305 
polymorphe, 382 

douleurt use r< cMivanti dt la 
grossesse, 387 
Dermatitis, 249 

blastomycetic, 825 
blastomycotica, 825 
calorica. 256 

treatment. '257 
congelationi-. 257 

treatment. 258 
contusiformis. 149 
epidemic exfoliative. 314 
exfoliativa. 305. 308 

diagnosis. 306 
etiology, 306 
pathology, 306 
prognosis, 307 
symptoms. 305 
treatment. 307 
neonatorum. 313 
etiology. 313 
pathology, 313 
prognosis. 314 
treatment. 314 
factitia. 272 
gangrenosa, 365 
prognosis, 369 
treatment. 368 
gangrenosa infantum. 367 
general exfoliative, 305 
herpetiformis, 3S2 
diagnosis. 3S5 
etiology. 3S4 
pathology. 385 
prognosis, 386 



Dermatitis herpetiformis, svmptoms, 
383 
treatment. 385 
in children. 387 
malignant papillary. 738 
medicamentosa, 250 
diagnosis. 271 
etiology, 271 
treatment. 272 
papillaris capillitii, 551. 9S6 
pemphigus-like, fatal, 382 
primary exfoliative. 316 
psoriasiformis nodularis. 304 
repens. 364 

scarlatiniformis recidivans, 139 
seborrhoi'ca, S95 
diagnosis. 902 
etiology. 901 
pathology. 901 
symptoms, 896 
treatment. 903 
secondary exfoliative, 317 
traumatica. 249 
vegetans. 343 
venenata. 250 

diagnosis. 254 
treatment. 255 
Dermatobia cuterebra, 1026 
eyaniventris, 1029 
hypoderma, 1026 
noxalis, 1026 
Dermatolvsis. 557 
Dermatomycosis furfuracea, S18 
Dermatophilus penetrans, 1026 
Dermatosclerosis, 504 
Dermatoses due to toxines of bacillus 

tuberculosis. 630 
Dermatosis. Kaposi, 593 
Dermite, 249 
Dermographism, 15S 
Desquamative scarlatiniform erythema, 

139 
Development of skin. 19 
Dhobie itch, 1037 

diagnosis, 1037 
treatment. 1037 
Diabetic gangrene, 366 
Diabetidf*. 186 
Diagnosis, general. 81 
Diffuse idiopathic atrophy. 522 
diagnosis. 522 
etiology. 522 
histology, 522 
symptom-. 522 
treatment. 522 
Dirt-eater's amemia. 1012 
Diseases due to vegetable parasites. 781 
of mucous membranes associated 

with dermatoses, 1081 
of tropics and warm countries, 1007 
Dissection wounds. 357 
treatment. 357 
tubercle. 609 
Disseminated ringworm. 798 
Distoma hepaticum. Q 40 



INDEX. 



1107 



Diuretics, 'J9 
Dochmiosis, 1012 
Dog-nose, 1074 
Dracontiasis, 1022 

diagnosis, 1024 

etiology, 1023 

pathology, 1023 

prognosis, 1024 

symptoms, 1022 

treatment. 1024 
Dracunculus medinensis, 1022 
Dragonneau, 1022 
Drug eruptions, 259 
Duhring's disease, 3S2 
Duke's disease, 442 
Dysidrose, 407 
Dysidrosis, 407 
Dyskeratosis, congenital, 452 
Dystrophie cedemateuse h6r6ditaire, 503 

papillaire et pigmentaire, 473 



Echinococcus, 848 

Ecthyma, 341 

diagnosis, 342 

etiology, 341 

pathology, 342 

treatment, 343 
Ecthyma terebrant, 307 
Eczem, 175 
Eczema, 175 

craquelc, 185 

exfoliant des levres, 10SS 
Eczema, 175 

diagnosis, 196 
etiology, 189 
pathology, 194 
prognosis, 224 
symptoms, 178 
treatment, 203 

acute. 188 

ani, 239 

aurium, 232 

barbae, 234 

capillitii, 226 

capitis, 226 

chronic, 1S9, 21S 

crurale, 242 

erurum, 242 

diagnosis, 242 
treatment, 243 

diabeticorum, 186 

erythematosum, 178 

exfoliativum, 185 

fissum, 185 

folliculorum, 187 

impetiginoides, 182 

intertrigo, 143 

labiorum, 230 

lichenoides, 179 

mammae, 241 

manuum, 244 

marginatum, 188, 795 

narium, 231 



if anus and 



region, 239 



in- ami anal region, 2 
i ment, 239 
Of heard, 234 

diagnosis, 235 

treatment, 235 
of breast, 241 
nt' children, 225 

treatment, 22.") 
of conjunctiva. 1081 
of car-. 232 

diagnosis, 233 

1 n at ment, 233 
of eye-lids, 233 

diagnosis, 234 

treatment, 234 
of face, 228 

diagnosis, 229 

treatment, 230 

Of feet. 2J4 

of genitalia, 236 

diagnosis, 237 

treatment, 238 

of hands, 244 

diagnosis, 246 

treatment, 240 
of lips, 230 

diagnosis, 230 

treatment. 231 
of nails, 248. 998 
of nipple, 241 

treatment. 241 
of nostrils, 231 

treatment, 232 
of scalp, 220 

treatment, 227 
of tropics, 248 
of umbilicus, 242 

treatment. 242 
palpebrarum. 233 
papulosum, 179 
parasiticum, 1S7 
pedum, 244 
pustulosum, 1S2, 184 
rhagadiforme. 185 
sclerosum, 186 
seborrhoi'cum, 895 
solare, 248, 1007 
squamosum, 185 
subacute, 217 
topical varieties, 225 
tuberculatum. 718 
tuberculous, of nurslings, 186 
umbilici, 242 
unguium, 248 
universal, 248 
verrucosum, 186 
vesiculosum, 181 
warty, 186 
Eczematous epitheliomatosis of nipple, 

738 
"Egg-foot," 1030 
Egg-shell nail, 994 

Eigenartiges psoriasiformis und lichen- 
oides exanthem, 304 
Eiterblase, 341 



1108 



INDEX. 



Eiterflechte, 336 
Eitergesehvmr, 345 
Elcthyma, 341 
Electrolysis, 121 
Elementary lesions, 56 
Elephant foot. 1030 

leg, 1013 
Elephantiasis Arabum, 1013 

Grsecorum, 1044 

lymphangiectatica, 573, 731 

tuberculosa cutis, 612 
Endemic degeneration of bones of foot, 

1030 
Endemische beulenkrankheit, 1060 
En (/clu re, 142 
Engman's salve, 275 
Envies, 907 
Eph Slide, 531 
Ephelis, 531 
Ephidrosis, 867 

tincta. 879 
Epidemic exfoliative dermatitis, 314 
etiology, 316 

herpetic fever, 371 

skin disease, 314 
Epidermis, 25 
Epidermolysis bullosa hereditaria, 412, 

histology, 413 
Epilation, 788 
Epithelial cancer. 735 

degeneration, 77 
Epithelialkrebs, 735 
Epithelioma contagiosum, 576 

deep, 739 

discoid, 736 

papillary, 740 

regional, 746 

superficial, 730 

tubercular, 739 
Epithe'liomatose pigmentaire, 503 
Epithclioiuc Jcystique b£nin, 592 
Epitrichial layer. 19 
Equinia, 355 

diagnosis. 356 

etiology. 350 

pathology, 356 

prognosis. 357 

symptoms. 355 

treatment. 357 
Erbgrind, 781 
Erectores pilorum, 37 
Ergot. 100 
Ergotine, 100 
Erntemilbe, S49 
Erosions, 62 
Eruption circinee chroniqut dv dos des 

mains, 156 
Eruptions medicamenteuses, 259 
Erysipel, 358 
Erysipelas, 358 

diagnosis, 362 
etiology. 361 
pathology, 362 
prognosis, 363 
symptoms, 359 



Erysipelas, treatment, 362 
ambulans, 360 
chronic, 361 
chronicum, 358 
Lombardy, 1069 
Erysipele, 358 
Erysipeloid, 358 

treatment, 358 

Erythanthema syphiliticum, 681 

Erythanthemata, 65 

Erythema ab igne, 136 

annulare, 147 

bullosum, 148 

vegetans, 404 
caloricum, 136 
chronic, multiforme, 156 
circinatum, 147 
contagiosum, 155 
elevatum diutinum, 156 
epidemicum, 1010 
exudativum multiforme, 146 
fig -ura turn. 148 

perstans, 155 
fugax, 137 

gangrenosum, 137, 272 
hypersemicum, 135 

diagnosis, 139 

treatment, 139 
induratum, 148, 629 

diagnosis. 630 

etiology, 630 

pathology, 630 

symptoms, 628 

treatment, 630 
infectuosum, 155 
intertrigo. 143 

diagnosis, 144 

etiology, 144 

symptoms, 143 

treatment, 145 
iris, 148 

lave. 137 

leprosum, 1049 
marginatum, 148 
migrans, 358 

multiforme. 146 

diagnosis. 153 

etiology, 151 

pathology, 152 

prognosis. 154 

symptoms, 146 

treatment, 154 
nodosum, 149 

pathology, 150 

symptoms, 149 
papulatum, 148 
papillosum. 148 
paratrimma, 137 
pernio. 142 

diagnosis, 142 

treatment. 142 
perstans. 154 

faciei, 154 
punctatum, 139 
scarlatiniforme, 139 



INDEX. 



1109 



Erythema scarlatiniforme, diagnosis, 139 
etiology, 140 
prognosis, 141 
symptoms, 140 
treatment, 141 

seleroticum, 156 

serpens, 358 

simplex, 135 

symptomatic, 137 

toxieum, 137 

traiunaticum, 136 

tuberculatum, 148 

tuberculosum, 148 

urticans, 137 

urticatum, 148 

variolous, 424 

venenatum, 137 

vesieulosum, 148 
Erythemato-sclcrose, 156 
Erythematous syphilid*, 658 
Eri/lliemc cent rif '////<', 636, 630 

indur6 des scrofuleux, 629 

infect ucu.c, 131) 

miliaire leucog^nique prurigi/tu ux 
chroniqae, 155 

noueux, 149 

polymorphe, 146 
Erythrasma, 823 

diagnosis, 824 

etiology, 824 

pathology, 824 

prognosis, 824 

symptoms, 823 

treatment, 824 
E'rythrodermie c.rfoliante, 305 

mycosique, 728 

pityriasique en plaques diss4mi- 
nees, 304, 718 
Erythromelalgia, 764 

etiology, 766 

pathology, 766 

prognosis, 766 

symptoms, 765 

treatment, 766 
Erythromelia, 522 
Es'thiomene, 008 
Etiology, general, 68 
Exanthemata, 65, 413 
Excoriations, 62 

neurotic, 882 
External auditory apparatus, diseases 
of, 1084 
otomycosis, 1084 
syphilitic lesions, 1084 

causes, 71 

treatment, 106 



Farcin, 355 

Farcy, 355 

Fat columns, 2 

Fat-cysts, sudoriparous, 9( 

Fatty degeneration, 80 

substances, 109 
Favic onychomycosis, 784 



Favus, 781 

of nails, i003, 784 
Favus des ongles, 1003 
Febris bullosa, 397 

Feigned eruptions, 272 

diagnosis, 273 

treatment, 274 
Feigivarze, 482, 682 
Fetid sweat, 877 
Fever blisters, 369 
Fibroma, 554 

diagnosis, 555 

etiology, 555 

pathology. 555 

prognosis, 556 
symptoms, 554 

treatment, 556 

fungoides, 7 is 

molluscum, 554 

pendulum, 557 

simplex, 556 
Fibromatosis tuberculosa cutis, 611 
Fibromyoma, 565 
Ficosis, 976 
Fig-wart, 182 
Filaria dracunculus, 1022 

medinensis, 1022 
Filariasis, 1013 

diagnosis, 1019 

etiology, 1017 

pathology, 1018 

prognosis, 1020 

symptoms, 1013 

treatment, 1020 
Filth, 73 

Fischschuppenau'sscMag, 494 
Fish oil, 116 
Fish-skin disease, 404 
Fissures, 63 
Flea, 847 

sand, 1026 
Flea-bites, treatment, 848 
Flechte, 369 
Flecke, 56 
Flecken, 414 
Fleckenmal, 489 
Flores unguium, 993 
Folliculite cicatricielle necrotique, 937 
Folliculitis. 344 

atrophicans, 984 
diagnosis, 085 
etiology, 985 
pathology, 985 
prognosis, 985 
symptoms, 984 
treatment, 985 

barbae, 976 

varioliformis, 937 
Formaldehyd, 116 
Fourth disease, 442 
Fragilitas crinium, 946 
Framboesia ti'opica, 1061 
Framosi, 1061 
Freckles, 531 
Friesel, 871 



1110 



INDEX. 



Frostbeule, 142 

Fungoid otitis externa, 1084 

Fungus foot of India, 1030 

Furoncle, 345 

Furrows of skin, 17 

Furuncle, 345 

Furuneulus, 345 

diagnosis, 347 

etiology, 346 

pathology, 347 

prognosis, 348 

symptoms, 345 

treatment, 347 
Furunkel, 345 



Gadbbeeze, 1029 
Gad-fly, 1029 
Gafsa button, 10GG 
Gale, 835 
Gangosa, 1076 

diagnosis, 1078 

symptoms, 1076 

treatment, 1078 
Gangrene, diabetic, 306 

hysterical. 272 

multiple, disseminated, in infants, 
307 

neurotic, 272 

nosocomial, 366 

of extremities, symmetrical. 369 

of skin, multiple, 365 

spontaneous, 272 
Gangrenous infantile ecthyma, 367 
Gastrophelus, 1028 
Gayle, 1079 
Gt fassmal, 567 
G< nn iner floh, 847 
General diagnosis, 81 

etiology. 68 

exfoliative dermatitis. 305 

pathology, 75 

prognosis, 92 

symptomatology, 55 

therapeutics. 04 
Geographical tongue, 1100 
Geschwiilste, 59 
Geschtoure, <i4 
Giant nsevus, 493 

urticaria. 160 
•• Gift-spots," 993 
Glanders, 355 
Glands. 43 

coil. 45 

excretory duct of. 46 

Meibomian, 45 

sebaceous, 43 

sebiparous, 43 

sweat. 45 

Tysonian, 45 
Glandulae ceruminosse, 45 

glomiformes. 45 
Glossitis areata exfoliativa. 1100 
Glossy fingers, 522 

skin. 522 



Glycerates, 110 
Glycerin, 110 
Glycerolates, 116 
Glycogelatins, 113 
Gnats, 864 
Gogo, 1037 
Goundou. 1074 
Granular layer, 28 
Granuloma annulare, 156, 3C4 
pathology, 157 
symptoms, 156 
treatment, 157 
fungoides, 718 
inguinale tropicum, 1065 
necrotic, 937 
sarcomatodes, 718 
telangiectatic, 572 
Granulosis rubra nasi, 883 
diagnosis, 885 
etiology, o84 
pathology, 884 
symptoms, 884 
treatment, 886 
Groin ulceration, 1065 
Gros nee, 1074 
Ground-itch, 1012 
Grutefo utel, 907 
Guiacol. 101 
Guinea-worm, 1022 

disease, 1022 
Guineesche Draake, 1022 
i. nne. 1037 
Gurtelausschlag, 374 
Giirtelflechte, 374 
Gutta rosea, 930 

H 

Haar8ackmilbe, 846 

Esemorrhagic variola, 428 
Hair, atrophy of, 946 

bulb, 41 

cortex, 4:; 

cuticle. 42 

deficiency of, 955 

dyes, 954 

follicle, 39 

follicles, diseases of, 939 

grayness of, 952 

hypertrophy of, 939 

medulla, 43 

nodose swellings of, 950 

shaft. 42 

shedding, deciduous. 087 

superfluous, 939 

whiteness of, 052 
Hairiness. 939 
Hairs-. 38 

headed. 040 

diseases of. 939 

expansions of. 950 

fissures of. 050 

moniliform. 040 
Hairy tongue, 1100 
Hang-nails. 997 
Hapalonychia, 002 



INDEX. 



1111 



" Earlequin" fcetus, 497 
Hwnschweiss, 881 
Earvest bug, 849 
Hautabschiirfungen, 62 
Hautentzimdv/ng, 249 
Hautfinne, 916 
Hawthorn, 479 
Hautschrunden, 03 
Hautsclerem, 504 
Head-louse, 854 
Heat-rash, 1007 
Heat-regulation, 52 
Hebra's diachylon salve, 215 
Hefenmykose, 825 
Hemangioendothelioma, 590 
Hematidrosis, 882 
Hemiatrophia facialis, 510 
Hemidrosis, 882 
Hemizona, 374 
Hemochromatosis, 534 
Hemorrhages, 445 
Henoch's purpura, 449 
Henpuye, 1074 
Heredity, 68 
Herpes, 309 

pathology, 373 
treatment, 3(3 

circinatus bullosus, 382 

desquamans, 1037 

facialis, 370 

febrilis, 370 

generalized, 371 

genitalis, 371 

gestationis, 382, 387 

iris, 148, 382 

labialis, 370 

menstrualis, 372 

phlyctsenoides, 3S2 

praqmtialis, 371 

progenitalis, 371 
diagnosis, 372 

pysemicus, 388 

simplex, 370 

tonsurans, 793, 790 
maculosus, 299 

vegetans, 404 

zoster, 374 

diagnosis, 380 
etiology, 378 
pathology, 379 
prognosis, 382 
symptoms, 374 
treatment, 3S0 
Herpes tonsurans desquamatif, 103/ 
Herpetic fever, epidemic. 371 
Herxheimers fibres, 29 
Hide-bound skin, 504 
Hidradenomes eruptifs, 592 
Hidrocvstoma, 874 
Hirsuties, 939 
Histology, 76 
Hives, 157 
Hoariness, 952 
Holsbock, 853 
Hook-worm, 1012 



Hook-worm disease, 1012 
Hornauswuchs, I7'.t 
Horn, cutaneous, 479 
llniin layer, 28 
Hilhnerauge, 477 
Hyalom der Haul, 586 
liyaloma, 580 

Hydradenitis suppurativa, 883 
etiology, 883 
pathology, 883 
symptoms, 883 
treatment, 8S3 
Hydroa, 3S2 

sestivale, 410 
bulleux, 387 
herpetiformis, 382 
puerorum, 410 
vacciniforme, 410 
diagnosis, 412 
etiology, 411 
pathology, 411 
prognosis, 412 
symptoms, 410 
treatment, 412 
Hydroa v^siculeux, 148 
Eydrocystoma, 874 ' 
diagnosis, 875 
etiology, 874 
pathology, 875 
symptoms, 874 
treatment, 870 
Eydrosis, 867 
I [yperaemia, 75 
ll\ persemias, 135 
Eyperaemic treatment, 120 
Hyperesthesia, 761 
Hyperhidrosis, 867 
Hyperidrose, 807 
Hvperidrosis, 807 
etiology, 869 
oleosa, 886 
pathology, 869 
prognosis, 871 
symptoms, 867 
treatment, 869 
Hyperkeratose figuree centrifuge atro- 
phia nte, 467 
Hyperkeratosis, 76 
excentrica. 407 
striata et follicularis, 472 
Hypersarcosis, 1013 
Hvpertrichiasis, 939 
Hypertrichosis. 939 
etiology. 942 
neurotica. 941 
symptoms, 939 
treatment, 942 
Hypertrophic cicatrix, 550 

scar, 550 
Hypertrophies, 451 
Hyphogenous sycosis, 798 
Hypodermatic injection, 102 
Hyponomoderma. 102S 
Hypotrichiasis. 955 
Hvsterical dermato-neuroses. 272 



1112 



INDEX. 



Hysterical gangrene, 272 



Ichthyol, 110, 110 
Ichthyose, 494 
Ichthyosis, 494 

diagnosis, 499 
etiology, 497 
pathology, 498 
prognosis, 499 
symptoms, 494 
treatment, 499 
congenita, 497 
cornea, 489 
follicularis, 458 
hystrix. 493, 496 
linearis neuropathica, 489 
linguae, 1088 

palmaris et plantaris, 461 
sebacea, S88 

cornea, 458 
simplex. 494 
Idiopathic multiple pigment-sarcoma, 

731 
Idrosis, 867 
Ipnis sacer, .174 
Impetigo, 330 
Impetigo contagiosa, 330 

diagnosis, 340 
etiology, 339 
pathology, 339 
symptoms, 338 
treatment. 340 
bullosa, 337 
gyrata, 337 
eezematodes, 182 
herpetiformis, 388 
diagnosis, 389 
etiology, 389 
pathology, 389 
prognosis, 389 
symptoms, 388 
treatment. 389 
Infection, 74 

coccidioidal. S33 
protozoic, S33 
Infectious granulomata of tropics, etc.. 

1044 
Infective angioma, 571 

folliculitis. Kiss 
Inflammation, 75 
Inflammations, 135 
Inflammatory fungoid neoplasm, 718 
Ingesta, 70 
Initial sclerosis. 050 
Insect wounds. 357 
Instruments. 122 
Intertrigo, 143 

Intracutaneous injection, 102 
Iodine. 98, 118 
Iron, 101 
Irritation, 73 
Itch, arm-pit, iu37 
crutch. 1037 



Itch, Dhobie, 1037 
ground, 1012 
the, 835 

washerman's, 10?7 
Ittiosi, 494 
Ixodes, 853 

J 
Jaborandt, 100 
Jacob's ulcer, ,37 
Jequirity, 118 
Jigger, 1026 

K 
Kahlheit, 955 
Earbunkel, 349 
Kelis, 549 
Keloid. 549 

diagnosis, 553 
etiology, 552 
pathology, 552 
prognosis. 554 
symptoms, 549 
treatment, 553 
cicatricial. 550 
of Addison, 500 
of Alibert, 549 
scar-. 550 
Keloid-acne. 551, 920. 986 
Keratoangioma, 470 
Keratodermia excentrica, 407 

of extremities, symmetrical, 461 
palmaris el plantaris, 401 
diagnosis, 405 
etiology, 404 
pathology, 405 
prognosis, 466 
symptoms, 402 
treatment. 405 
KSratodermie palmaire et plantaire, 461 
Keratolysis exfolial iva congenita, 166 
neonatorum, 313 
of skin. 141 
Keratoma of the palms and soles, con- 
genita]. 40] 
Keratose folliculaire, 158 

pilaire < ngainante, 450 
Keratosis, 451 

follicularis, 458 

diagnosis, 460 
etiology, 459 
pathology, 459 
prognosis, 401 
symptoms, 458 
treatment. 401 
contagiosa, 472 
spinosa, 450 

etiology. 450 
histopathology, 456 
symptoms, 450 
treatment, 456 
nigricans, 473 

palmar and plantar, acquired, 463 
arsenical type, 463 
hyperidrosis type, 463 
congenital, 462 
pigmentosa, 483 



INDEX. 



1113 



Keratosis pilaris, 453 

diagnosis, 455 

pathology, 454 

symptoms, 453 

treatment, 455 
senilis, 457 

prognosis, 458 

symptoms, 457 

treatment, 457 
universalis, 497 
vegetans, 458 
Kerion, 798 
Kerion Celsi, 798 
Klammann's dusting-powder, 145 
Kiel ncnfl edit e, 818 
KnocJcelkoorks, 1010 
Enollenkrebs, 54!) 
Knotchen, 57 
Knoien, 58 
Koilonychia, 992 
Kra-kra, 1072 

Krankheit der Franzosen, (S47 
Emtise, 835 
Kraurosis vulvae, 524 

etiology, 525 

pathology, 526 

prognosis, 526 

symptoms, 525 

treatment, 520 
Krithoptes monunguiculosus, 850 
Kro-kro, 1072 
Krusten, 62 
Kuhpocken, 437 
Kupferfinne, 930 
Kupferrosc, 930 
Kyste scbacce, 907 



Labialitis, 1086 
Ladrerie, 1044 
Lata Tokelau, 1037 
Lanolin, 115 
La rosa, 1069 
La rose, 358 
Larva migrans, 1028 
Lassar paste, 110 

Duhring's modification of, 111 
Lausesucht, 853 
Lebbra, 1044 
Leichdom, 477 
Lentigo, 531 

etiology, 532 

pathology, 532 

symptoms, 531 

treatment, 532 
maligna, 593 
Lentille, 531 
Leontiasis, 1044 
Lepothrix, 951 
Lepra, 276, 1044 

diagnosis, 1057 

etiology, 1054 

pathology, 1055 



prognosis, 1060 



Lepra, symptoms, L046 
treatment, 1058 
ansesthetica, L050 
Arabum, 1044 
fungifera, 1061 
[talica, L069 
maculo-aneesthetic, 1049 
maculosa, 1049 
tuberosa, 1047 
Ldpre, 1044 
Leprosy, 1044 

atrophic, 1050 
bacillus. 1056 
Lombardy, 1069 
nodulated, 1047 
tegumentary, 1047 
fcuberculated, 1047 
Leprous roseola, 104 ( .i 
scleroderma, L048 
Leptus, 849 

Americanus, 850 
autumnalis, 849 
irritans, 850 
Lesions, consecul ive, 61 
elementary, 56 
unclassified, 65 
Leucasmas, 538 
Leucoderma, 538 
acquired", 540 
congenital, complete, 539 
syphiliticum, 66] 
Leucokeratosis buccalis, 1088 
diagnosis, 1090 
etiology, 1090 
pathology, 1090 
prognosis, 1091 
symptoms, 1089 
treatment, 1091 
Leucoma, 1088 
Leucoplakia buccalis, 1088 
Leucoplasia, 108S 
Leucoplasie, 1088 
Leucosmus, 538 
Leukasmus, 540 

congenital, 539 
Leukemia cutis, 726 
etiology, 727 
pathology, 727 
symptoms, 726 
treatment, 728 
Leukonychia, 993 
unguium, 993 
Leukosmus, 540 

congenital, 539 
Lichen annularis. 156 
eczematodes, 179 
pilaris, 453, 456 
planus, 323 

diagnosis, 330 
etiologv, 328 
pathology, 329 
prognosis, 332 
symptoms, 324 
treatment, 330 
morphceicus, 332 



1114 



INDEX. 



Lichen planus annularis, 332 

of mucous surfaces, 335 
sclerosus et atrophicus, 332 
psoriasis, 317, 323 
ruber, 317, 322 

acuminatum, 317, 322 
planus, 323 
scrofulosorum, G30 
diagnosis, 632 
etiology, 631 
pathology, 631 
prognosis, 632 
symptoms, 630 
treatment, 630 
scrofulosus, 630 
simplex, 179 
spinulosus, 334, 456 
pathology, 334 
tropicus, 248, 1007 
diagnosis, 1008 
treatment, 1008 
urticatus, 159 
Lichenification, 336 
Linear nsevi, 482, 590 
Linimentum exsiccans, 113 
Linsenmal, 489 
Lioderma essentialis cum melanosi et 

telangiectasia, 593 
Liparis chrysorrhcea, 851 
Lipoma, 561 

diagnosis, 562 
etiology, 562 
pathology, 562 
prognosis, 562 
symptoms, 561 
treatment, 562 
Liquid air, 132 
Liquor carbonis detergens, 214 

picis alkalinus, 221 
Lister's salve, 241 
Livedo. 139 
Liver fluke, 849 
Local asphyxia, 369 
Lombardy erysipelas, 1069 

leprosy, 1069 
Louse, body, 857 
crab, 860 
head, 854 
pubic, 860 
Lousiness, S53 
Lucilia Caesar, 1026 
Lues venerea. 647 
Lumpy-jaw, 1034 
Lupani, 1061 
Lupus crustosus, 606 
disseminatus, 639 
elephantiaticus, 604 
elevatus, 603 
endemicus, 1066 
erythematodes, 636 
erythematosus, 636 
diagnosis, 642 
etiology, 640 
pathology, 641 
prognosis, 647 



Lupus erythematosus, symptoms. 
636 
treatment, 643 
unusual types of, 639 
exfoliativus, 605 
exuberans, 604 
exulcerans, 606 
fibrosus, 605 
fungoides, 606 
fungosus, 606 
gangraenosus, 606 
hypertrophicus, 604 
keloides. 606 
lymphaticus, 574 
nodosus, 603 
non-exedens, 603, 636 
non-ulcerosus, 603 
cedematosus, 604 
of ears, 608 
of extremities, 608 
of face, 607 
of genital region, 608 
of mucous membranes, 608 
of trunk, 608 
papillosus, 604 
profundus, 606 
psoriasiforme, 605 
psoriasis, 605 
rodens, 606 
rupioides, 606 
sclerosus. 605, 611 
sebaceous, 636 
serpiginosus, 606 
superficialis, 606, 636 
tuberculatus, 603 
tumidus, 603, 604 
vegetans, 606 
verrucosus, 611 
vulgaris, 603 
Lupus dfmisclereux de In langue, 609 
papillaire verruqueux, 611 
scUreux, 605, 611 
Lnsiseuche, 647 
Lympha denecta sia, 573 
Lymphad&nie cutan4e, 718 
Lymphangiectasis, 470, 573 

suppurative tubercular, 615 
Lympliangiectodes. 574 
Lymphangioma, 572 

capillare varicosum, 574 
cavernosum, 574 
circumscriptum, 574 
etiology, 575 
pathology, 576 
symptoms, 574 
treatment, 576 
cystic. 57-t 
simple. 573 

tuberosum multiplex, 592 
Lymphangiomyoma. 565 
Lymphangitis tuberculosa cutanea, 616 
Lymphatic vessels. 31 
Lymphodermia perniciosa, 718, 728 
Lymph-scrotum, 1016 






INDEX. 



1115 



McCall Anderson's ointment, 109 
Macrochilia, 573 
Macroglossia, 573, 1100 
Maculae, 56 

coeruleae, 862 
Maculo-papnles, 57 
Madura disease, 1030 

foot, 1030 
Madurafuss, 1030 
Mai de Cayenne, 1013 
de los pintos, 1039 
de Meleda, 467 
perforant du pied, 526 
Pintado, 1039 
roxo, 1069 
Maladie de Duhring, 382 
Maliasmus, 355 
Malignant papillary dermatitis, 738 

pustule, 352 
Malleus, 355 
Maltine, 101 

Malum perforans pedis, 526 
Marsden's paste, 758 
Maseru, 414 
Mast-cells, 79 
Measles, 414 
Medina worm, 1022 
Melanoderma cachecticorum, 533 

of scrofulous, 636 
Melanosis lenticularis progressiva, 593 
Melanotic carcinoma, 744 
sarcoma, 729 
whitlow, 730 
Membranes, muscular, 3S 
Mentagra, 976 

parasitica, 799 
Meralgia paresthetica, 764 
Mercury, 98, 119 
Meta-arsenious-anilide, 98 
Microsporon furfur, 819 
Miliaria, 1007 

crvstallina, S71 
rubra, 248 
Miliaire, 1007 

crystalline, 871 
scrofuleuse, 937 
Miliary fever, 873 
Milium, 905 

diagnosis, 906 
etiology, 905 
pathology, 905 
prognosis, 906 
symptoms, 905 
treatment, 906 
colloid, 586 
congenitale, 906 
en plaques, 906 
Milzbrand, 352 

Karbunkel, 352 
Mineral Avaters, natural, 105 
Minor operations, 121 
Mistura ferri acida, 99 
Mitesser, 911 



Mole, pigmentary, 489 
Molluscum epitheliale, 576 
diagnosis, 578 
etiology, 577 
pathology, 577 
prognosis, 579 
symptoms, 576 
treatment, 579 
sebaceum, 576 
verrueosum, 576 
Mongolian pigment spots, 535 
Monilethrix, 949 
Morbilli, 414 
Morbus coeruleus, 139 
gallicus, 647 

maculosus Werlhofii, 448 
pediculosis, 853 
pedis entophyticus, 1030 
tuberculosus pedis, 1030 
MoroigUone, 435 
Morphcea, 506 

guttata, 333, 509 
Morpion, 860 

Morvan's disease, 528, 997 
diagnosis, 528 
etiology, 528 
pathology, 528 
symptoms, 528 
treatment, 529 
Morve, 355 
Mosquitoes, 864 
Mountain anaemia, 1012 
Mouth, actinomycosis, 1095 
adenoma sebaceum, 1094 
angioneurotic oedema, 1093 
Bael's disease, 1088 
blastomycosis, 1097 
cancer. 1096 
cheilitis, 1087 

glandularis, 1088 
erythema multiforme, 1092 
erythematous keratosis, 1092 
Fordyce's disease, 1086 
herpes zoster, 1092 
lepra, 1097 

leucokeratosis buccalis, 10S8 
leukaemia, 1093 
lichen planus, 1094 
lupus ervthematosus, 1094 

vulgaris. 1094 
measles, 1092 
pciiecne, 1086 

pre-cancerous keratosis, 1095 
pseudo-colloid of lips, 1086 
pseudo-herpetic lesions, 1093 
jasoriasis, 1092 
scarlet fever, 1092 
scurvy, 1096 
syphilis, 1095 
urticaria, 1093 
vaccinia, 1092 
variola, 1091 
xanthoma, 1093 
Mower's mite. 849 
Moyocuil, 1029 



1116 



INDEX. 



Mucoid degeneration, 80 
Mucous patches, 682 
Multiple benign cystic epithelioma, 590 
etiology, 591 
pathology, 591 
prognosis, 592 
symptoms, 591 
treatment, 592 
disseminated gangrene in infants, 
307 

sarcoid, 734 

histology, 735 
symptoms, 734 
treatment, 735 
tumor-like new-growths, 524 
tumors of skin with intense pru- 
ritus, 174 
Musca domestica, 1020 

stabulans, 1026 
Muscidae, 1026 
Muscles, 37 

non-striated, 37 
striated. 37 
Mycetoma. 1031 

diagnosis, 1033 
etiology, 1033 
pathology, 1033 
prognosis. 1034 
symptoms, 1031 
treatment, 1034 
Mi/cctonic, 1030 
Mycosis cutis chronica, 1066 
fungoides. 718 

diagnosis, 725 
etiology, 723 
pathology, 723 
prognosis', 726 
symptoms, 7 is 
treatment. 725 
erythematous period, 718 
lichenoid period, 719 
period of infiltration. 719 
stadium eczematosum, 718 
microsporina, 818 
Mycotic dermatitis of tropics, 1037 
Myiasis, 1026 

dermatosa, 1026 
externa, 1026 
interna, 1026 
intestinalis, 1026 
Myoma, 565 

diagnosis. 560 
symptoms, 5b5 
treatment. 500 
dartoic, 505 
simple. 565 
telangiectodes, 565 
Myringomycosis, 1084 
Myxadenit'is labialis, 1088 
Myxoedema. 515 
prognosis, 516 
symptoms. 515 
Myxomatous degeneration, 80 



N 

Nackenkeloid, 986 
Naevi, linear, 590 
Xaevoid elephantiasis, 1016 
Naevus araneus, 568, 930 
flammeus, 567 
giant, 493 
lupus*, 571 
nervosus, 489 
pigmentosus, 489 
pilosus, 489 
sanguineus, 567 
spileus, 489 
unius lateris, 489 
vasculosus, 567 
yerrucosus, 489 
Xaftalan, 117 
Nail bed, 49 

syphilis- of, 1005 
egg-shell, 994 
fold, 49 
lunula, CO 

matrix, syphilis of, 1005 
plate, 50 

syphilis of. 1005 
true matrix, 49 
Nails. 48 

chancres of. 1004 
congenital anomalies, 989 
diseases of. 988 
acquired, 991 
associated with congenital 

dermatoses, 989 
induced by dermatoses of ex- 
tremities, !MtS 

favus «»f, loo:; 

ringworm of. 1003 

-syphilis of. 1004 
Naphtol, 117 
Narbe, 54 7 
Narben, 64 
Nasal cavities, ios4 

glanders, 1085 

lepra, 1085 

rhinoscleroma, 1085 

syphilis, 1085 

tuberculosis. L085 
Xatal sore, 1066, 1079 
Necrotic granuloma. 937 
Nectator Americanus, 1012 
Nerve fillers, medullated, 32 
non-medullated, 32 

leprosy, 1050 
Nerves, 32' 

tumor of, 563 
Xeryous system, 69 
Nesselcmssch la ft, 157 
Nesselsucht, 157 
Xettle-rash. 157 
Neuralgia cutis, 762 

red. 764 
Xeurodermia, 769 
Xeurofibroma, 554 
Xeurom, 563 
Xeuroma. C63 



INDEX. 



1117 



Neuroma, pathology, 564 

symptoms, 503 
Neuropathic plica, 941 
Neurotic excoriations, 882 

gangrene, 272 
Nevocarcinoma, 729 
Nevomelanoma, 729 
Nevrome, 562 
New-growths, 547 
Niardi, 1086 
Nietnagel, 997 
Nigua. 1026 

Nodose swellings of hair-shafts, 950 
Nodositas crinium, 947 
Nodules, 58 
Noli-me-tangere, 737 
Nosocomial gangrene, 366 



Occupation, 72 

(Edema, circumscribed and persistent, 
170 
cretinoid, 515 
neonatorum, 501 
diagnosis, 502 
etiology, 501 
pathology, 501 
prognosis, 502 
symptoms, 501 
treatment, 502 
(Edematous degeneration, 80 
CEil de perdrix, 477 
(Estrus bovis, 1029 

hominis, 1029 
Oily substances, 109 
Oleates, 115 

Oligotrichia congenita, 955 
Onychatrophia. 991 
Onychatrophie, 991 
Onychauxis, 994 

compensatory, 994 
non-compensatory, 996 
with hyperidrosis, 995 
with keratoma, 995 
Onychia. 996 

friable, 1005 
maligna, 997 
Onychitis, 996 

Onychogryphosis congenita, 990 
Onycholysis. 992 
Onychomadesis, 9S9, 992 
Onychomycoses 1003 

favique, a.003 
Onychomycosis, 784, 1002 
treatment, 1003 
favosa, 1003 
trichophytina, 1003 
Onychoptosis, 992 
Onyxis craquele. 1005 
Opaline plaques, 683 
Opsonins, 102 
Oriental button, 1066 
sore, 1066 

diagnosis, 1068 
etiology, 1067 



Oriental sore, pathologj . L067 
prognosis, L068 
symptoms, 1060 
treatment, 1068 
ulcer, L066 

Oroya fever, 1063 

Or lie, 157 

Osmidrosis, 877 

Osteoma cutis, 566 

Osteosis cutis, 566 

Otitis externa, fungoid. 10.S4 

Otomycosis, 1084 



PACHYDEBMATOCELE, 557 
Pachydermia, 1013 

lymphangiectatica, 573 
Pachyonychia congenita, 990 
Pacinian corpuscles, 32 
Paget's disease, 241, 738 
Pain sense. 54 

Panaris analgisique, 528, 997 
Panaritium, 997 
Panniculus adiposus, 20 
Papillary epithelioma, 740 
Papilloma neuropathicum unilaterale, 

489 
Papulae, 57 
Papules, 57 

Papulose filarienne, 1072 
Papulo-tubercles, 59 
Paresthesia cutis. 767 
Paraffin prosthesis, 558 
diagnosis, 560 
histopal nology, 559 
prognosis. 560 
treatment, 560 
Parakeratosis, 77 

scut ula lis. 472 

variegata, 303 
Parangi, 1061 
Parapsoriasis, 303 
Parapsoriasis en gouttes, 304 

en plaques, 304 

lichenoids, 303 
Parasitdre Bartfinne, 799 
Parasites. 74 

animal, S34 
Parasitic affections. 781 

diseases', 74 
Paratuberculoses, 632 
Paronychia. 997 

syphilitica ulcerosa, 1005 
Pars papillaris, 23 

reticularis. 23 
Paste-pencils, 115 
Pastes, 110 

dextrin, 111 

gum, 112 

kaolin. 111 

lead, 111 

sulphur. Ill 
Pathology, 75 
Pediculid'a?. 853 



1118 



INDEX. 



Pediculosis. S53 
eapillitii. S54 

diagnosis,. 856 
treatment, S56 
corporis, S57 

diagnosis. S59 
treatment, 860 
pubis, 860 

diagnosis, S61 
treatment, S62 
vestimenti, 857 
Peitschemourm, 1022 
Pelade, 966 
Pellagra, 1069 

diagnosis, 1072 
etiology, 1071 
pathology, 1071 
prognosis, 1072 
symptoms. 1069 
treatment. 1072 
Pellarella. 1069 

Pemphigoid sclerotic ervthema, 156 
Pemphigus, 3S2, 390 

diagnosis. 394 
etiology, 391 
pathology, 392 
prognosis. 397 
symptoms, 390 
treatment. 396 
acutus, 397 

contagiosus adultorum, 336 
benignus, 401 
chloroticus, 404 
chronicus, 400 
circinatus. 382. 401 
contagiosus. 399 

neonatorum acutu>. 399 
of tropics, 1008 

diagnosis. 1009 
etiology, 1009 
pathology, 1009 
treatment, 1010 
disseminatus, 401 
epidemicus. 399 
febrilis. 397 
foliaceus. 402 
gaugraenosus. 367 
haemorrhagicus, 401 
hystericus. 3S7 
in children. 407 
inherited. 404 
-like dermatitis, fatal, 382 
neonatorum, 33S, 399 
of mucous surfaces. 406 
of young girls. 404 
pruriginosus. 402 
solitarius, 401 
syphiliticus. 674 
vegetans. 404 
virginum. 404 
Pemphir/us aigu prurigineux, 3S2 
compose, 382 
prurigineux, 382 
Perforating granuloma of thigh, 1065 
ulcer of foot. 526 



Perforating ulcer of foot, diagnosis, .527 
etiology, 527 
pathology, 527 
prognosis, 527 
symptoms. 526 
treatment, 527 
Perical, 1030 
Perifolliculitis, 344 
pathology, 345 
treatment. 345 
Perleche, 1086 

diagnosis, 10S7 
etiology, 1087 
pathology, 1087 
symptoms, 10S7 
treatment, 1087 
Pernio. 142. 257 
Peruvian wart. 1061. 1063 
Petite oSrole, 424 
Phagedama tropica. 1042 
etiology, 1043 
pathology, 1043 
prognosis. 1044 
Bymptoms, 1043 
treatment. 1044 
Phenol-camphor, 120 
Phlegmon, progressive, 358 
Phlegmone diffusa, 352 
symptoms. 352 
treatment. :;:>2 
Phlyctenae, 59 
Phlyctenule. .V.i 
Phosphoridrosis, 882 
Phosphorus, 101 
Phototherapy, 127 
Phtheiriasis, 853. 857 
Phthirioee, 853 
1 Phymata. 59 
Physiological crises, 70 
Physiology of skin, 17. 51 
Pian. 1061 
Pick's gelatin sublimate. 217 

salicylated soap plaster, 220 
tragacanth varnish, 217 
varnish. 113 
Piebald skin. 540 
Pied tie Madure, 1030 
Piedra. 1041 

diagnosis, 1042 
etiology. 1042 
nostras. 952 
pathology, 1042 
treatment. 1042 
Pigment, 36 

anomalies. 531 
Pigmentary mole. 489 
syphil'irle, 661 
tuberculide, 636 
Pigmentation from arsenic-ingestion, 
534 
of skin following shock, 535 
Pigmented carcinoma, 744 
Pili annulati. 949 
Pilocarpine. 100 
! Pint a. 1039 



INDEX. 



111!) 



Pinta, diagnosis, 1041 
etiology, 1041 
pathology, 1041 
prognosis, 1041 
symptoms, 1040 
treatment, 1041 
Pinto, 103!) 

Piroplasmosis hominis, 443 
Pita, 1037 

Pityriasis capitis, 9G0 
circinata, 299 
linguae, 1100 

maculata et circinata, 299 
nigricans, 879 
pilaris. 317, 453 
rosea, 299 

diagnosis, 301 
etiology, 300 
pathology, 301 
symptoms, 299 
treatment, 302 
rubra (Hebra), 308 

diagnosis, 311 
etiology, 310 
pathology, 310 
prognosis, :',]■! 
symptoms, 30S 
treatment, 311 
pilaris, 317 

diagnosis, 321 
etiology, 320 
pathology, 320 
prognosis, 322 
symptoms, 317 
treatment, 321 
versicolor, 818 
Pityriasis circine et margine, 299 
dissemine, 299 
des Uvres, 10S8 
rose de Gibert, 299 
rubra aigu, 299. 308 
rubra pilaire, 317 
Plantaria, 1010 

Plaques blanches de la bouche, 1088 
Plaques jaundtres des paupieres, 571 
muqueuses, 682 
ortiees, 58 
Plasma cells, 78 
Plasters, 114 
Plica, neuropathic, 941 

polonica, 941 
Pocken, 424 
" Pocks," 424 
Podelcoma, 1030 
Poils accidentels, 939 
Poison ivy, 250 
Poissonade, 1086 
Poliosis, 952 
Poliothrix, 952 
Polydactyly, 989 
Polyidrosis, 867 
Polypapilloma tropicum, 1061 
Polytrichia, 939 
Pomphi, 58 
Pompholyx, 390, 407 



I Pompholyx, diagnosis, 409 
ci iologj . 408 
pathology, 409 
symptoms, 407 
treatment, 410 
Ponnus carateus, 1040 
Porokeratosis, 467 
histology, 469 
pathology, 469 
prognosis, 470 
symptoms, 468 
1 reatment, 470 
Porrigo contagiosa, 336 
decalvans, 966 
favosa, 781 
larvalis, 336 
Porthesia cbrysorrhoea, 851 
Post-mortem tubercle, 609 
Potassium permanganate, 119 
Pou de birs, 853 
Poultices, 1 15 
Powders, 114 
Pox, 647 

" Prairie itch," 769, 779 
prognosis, 780 
treatment, 780 
Prickly heat, 248, 1007 
Primary exfoliative dermatitis, 31( 

sore, 650 
Prognosis, general. 92 
Progressive phlegmon, 358 
Protection, 51 
Protozoa, 865 
Protozoic infection, 833 
Prurigo, 170 

diagnosis, 173 
etiology, 171 
pathology, 172 
prognosis, 174 
symptoms, 171 
treatment, 173 
agria, 170 
ferox. 170 
gravis, 170 
mitis, 170 
nodularis, 174 
etiology, 175 
pathology, 175 
symptoms, 174 
prognosis, 175 
treatment, 175 
of Hebra, 170 
Pruritus, 768 

diagnosis, 770 
etiology, 770 
pathology, 771 
prognosis, 776 
symptoms, 768 
treatment, 772 
ani, 770, 776 
etiology, 777 
treatment, 777 
bath. 769 
genitalium, 770 
hiemalis, 769, 776 



1120 



INDEX. 



Pruritus linguae, 770 
narium, 770 

palmae et plantae, 770 
senile, 769 
vulvae, 770 

etiology, 778 
symptoms, 777 
treatment. 77S 
Pseudo-atheroma, 907 
Pseudoleukemia cutis. 728 
Pseudoxanthoma elasticum. 586 
Psora. 270 
Psoriasis, 276 

diagnosis, 285 
etiology, 282 
pathology, 284 
prognosis, 298 
symptoms, 276 
treatment. 288 
external, 291 
systemic, 288 
buccal, 1088 
circinata, 277 
diffusa. 277 
discoidea, 277 
figurata, 277 
follicularis, 277 
guttata. 277 
gyrata, 277 
inveterata, 277 
labialis, 1088 
lingua'. 1088 
mucous. 683 
nummularis. 277 
of nails. 999 
orbicularis. 277 
ostreacea, 2sl 
punctata, 277 
rupioides, 281 
verrucosa. 281 
Psorospermost folliculaire vigitante, 

45S 
Psorospermosis, 458 
cutaneous, 738 
Pterygium of nail, 997 
Pubic louse, 860 
1'iicc commune, 847 

sable, 1026 
Pulex irritans. S47 
Punaise des lits, S(i3 
Purpura, 445 

diagnosis. 447 
etiology. 445 
pathology. 440 
prognosis. 447 
symptoms, 446 
treatment. 447 
cachectic. 445 
clinical varieties, 447 
hemorrhagica. 44S 
Henoch's. 449 
idiopathic. 440 
mechanical, 446 
nervous. 440 
rheumatica. 447 



Purpura, secondary, 445 

simplex, 447 

toxic, 445 

urticata, 159 
Pusteln, 60 
Pustulse, 60 
Pustule maligne, 352 
Pustules, 60 

from reptile and insect wounds, 357 

post-mortem. 357 
Pyodermite v4getante, o43 
Pvoktanin-blue, 119 
Pyrogallol, 118 

Q 
Quaddeln, 58 
Quijila, 1074 
Quinine. 100 

Quinquaud's disease, 984 
Quirica, 1039 



Radezyge, 647 

Radiotherapy, 123 

Radium, 131 

Raynaud's disease, 369 

Recurrent summer eruption, 410 

Red gum, 1007 

Reptiles, wounds, 357 

Resorcin, 101. 117 

Respiration, 54 

Rhagades, 63 

Rheumatismus febrilis epidemicus, 1010 

exanthematosus, 1010 
Rhinophyma, 931 
Rhinoscleroma, 600 

diagnosis, 001 

etiology, 600 

pathology, 600 

prognosis, 602 

symptoms, 600 

treatment, 602 
Rhynchota, 853 
Rhynocoprion penetrans, lu26 
Ridges of skin, 17 
Rimse, 63 

" Ringed eruption." 156 
Ringelhaaren, '.i4!i 
Ringworm, 790 

Bowditch Isiand. 1037 

Burmese. 1037 

Chinese, 1037 

disseminated, 798 

honeycomb, 781 

India. 1037 

of beard. 799 

of nails, 1003 

of scalp. 790 

scaly. 1037 

•• scrofulous," 036 

Tokelau. 1037 
Risipola Lombarda. 1009 
Patter's disease, 313 
Rocky Mountain spotted fever, 443 
etiolosrv, 444 



INDEX. 



1121 



liocky Mountain spotted fever, pathol- 
ogy, 444 
prognosis, 444 
symptoms, 443 
treatment, 444 
Rodent ulcer, 735, 737 
Root-sheath of hairs, 40 
inner, 40 
outer, 40 
Rosacea, 930 
Roseola infantilis, 138 

leprous, 104'J 

scarlatiniforme, 139 

syphilitic, 658 

variolous, 424 
Ixoscolc squameuse. 2!)!) 
Rosolia, 414 
Rothcln, 418 

diagnosis, 418 

etiology, 418 

pathology, 418 

symptoms, 418 

treatment, 419 
Rot he Schwindflechte, 322 
Rothklcie, 308 
Rothlauf, 358 
RotzkrankJieit, 355 
Rougeole, 414 
Rouget, 849 
Rubeola, 414 

diagnosis, 416 

etiology, 416 

pathology, 416 

prognosis, 417 

symptoms, 417 

treatment, 417 
Rupia escharotica, 367 



SaccharomycosIvS hominis, S25 
Salicylic acid, 117 
Salol, 100 
Salve-pencils, 115 
Sand flea, 1026 

bites, 1026 
Sandfloh, 1026 
Sarcoid growths, 734 

multiple, benign, 734 
tumors, 156 
Sarcoma cutis, 728 

diagnosis, 733 
etiology, 732 
pathology, 732 
prognosis, 734 
symptoms, 729 
treatment, 734 
idiopathic, multiple, pigment, 731 
symptoms, 731 
etiology, 732 
pathology, 732 
melanotic, 729 
mucosum, 1013 
primary, non-pigmented, 730 
Sarcomatosis generalis, 718 
Sarcome angioplastique reticule, 572 

71 



Sarcopsylla penetrans, 1026 
Sarcoptes, 841 

Wohlfarti, 1026 
auchenii, 841 
cameli, 841 
canis, 841 
caprse, 841 
communis, 841 
equi, 841 
hominis, 841 
ovis, S41 
scabiei, 835, 841 
suis, 841 
vulpis, 841 
Sartian disease, 1060 
Satyriasis. 1044 
Savill's disease, 314 
Scabies, 835 

diagnosis, 842 ^--^ 
etiology, 840 
pathology, 841 
prognosis. 845 
symptoms, 835 
treatment, 843 
Norvegica, 840 
Scabrities unguium syphilitica, 1005 
Scabs, 62 
Scales, 61 
Scaly patches. 683 

ringworm, 1037 
Scar, 547 

hypertrophic, 550 
Scarf-skin, 25 
Scar-keloid, 550 
Scarlatina, 419 

diagnosis, 423 
etiology, 422 
pathology, 422 
prognosis, 424 
symptoms, 41!) 
treatment, 423 
anginose, 421 
septic, 421 
toxic, 421 
Scarlatine, 419 

foudroyante, 421 
Scarlatiniform typhus, 421 
Scarlatinoide, 139 
Scarlatinoid erythema, 139 
Scar-leaving sycosiform dermatosis, 978 
Scarlet fever, 419 

rash, 139, 419 
Scars, 64 
Scharlach, 419 
Scheerende Flechte. 796 
Scheme for recording cases of skin dis- 
ease, 90 
Schimmelpelzmykosen der Nagel, 1003 
Schleim hautpapehi, 682 
Schmeerfluss, 885 
Schuppen, 61 
Schujypenflechte, 276 
Schwammformige, 1061 
Schircissdrusen Adenom mit Cystcn- 
bildung, 592 



1122 



INDEX. 



Bchweissflechte, 1007 
Sclerema adultorum, 504 
neonatorum, 502 
etiology, 503 
pathology, 503 
prognosis, 503 
symptoms, 502 
treatment, 503 
of new-born, 502 
Sclereme des nouveau-nes, 502 
Scleriasis, 504 
Sclerodactylia, 510 
Scleroderma, 501, 504 
diagnosis, 512 
etiology, 510 
pathology, 511 
symptoms, 504 
treatment, 513 
alba, 508 
atrophica, 508 
circumscribed, 50G 
lardacea, 508 
leprous, 1048 
maculosa, 508 
neonatorum, 502 
nigra, 508 
plana, 508 
SclSroderm ic, 502 
Sclerosis, initial, G50 
Sclerotizing granuloma of pudenda, 

1065 
Scratching, 71 
Screw-worm, 1027 
Scrofulide eryth&mateuse, G3G 
Scrofuloderma, 613 
Scrofuloderma verrucosum, Gil 
Scrofuloderma, ulcerative, 718 
•• Scrofulous ringworm." 636 
Scurvy. Alpine, 1009 
Seasons, 72 

Sebaceous cystic disease, 910 
eysts, 907 
flux, 885 
glands, 885 
tumor, 907 
Seborrhagia, 885 
MborrMe, 885 

dcpikinte, 978 
Seborrhoea, 885 

diagnosis, 890 
etiology, 889 
pathology, 889 
prognosis, 895 
symptoms. 886 
treatment, 891 
congestiva, 636 
corporis, 900 
oleosa. 886 
sicca, 886 
simplex, 886 

squamosa neonatorum, 888 
Secondary exfoliative dermatitis, 317 
Secretion, skin, 52 
Sensation, 53 
Sensory dermato-neuroses, 761 



Septum lucidum, 28 
Scrum/lion, 414 

Serpiginous ulceration of genitals, 1065 
Sex, 69 

Sexual system. 70 
Shedding of skin. 141 
Sheep camp fever, 443 
Shingles, 374 
Sifilide, 647 
Sifilis, 647 
Simulia, 8G5 
Sirop de Gibert, 708 
Skin eruption, peculiar, in pregnancy, 
382 

lax, 557 

relaxed, 557 

true, 21 
Sleeping sickness, 1021 
Slipada, 1030 
Small-pox, 424 

black, 428 
Smokers' patches of mouth, 1088 
Soaps, 108 

medicated, 109 

over-fatty, 108 

superfatted, 108 
Sodium cacodylate, 97 
Solar heat, 71 

light, 71 
Sommersprosse, 531 
Spargosis fibro-areolaris, 1013 
Spedahkhed, 1044 
Sphaceloderma. 303 
" Spider cancer." 568 
Spiral fibers, 29 
Spirochete pallida, 691 
Spitzblattern, 435 
Spitzencondylom, 482 
Bpitzemoarge, 482 
Splenic fever carbuncle, 352 
Spontaneous gangrene, 272 
•• Spoon-nails," 992 
Sporotrichosis, 833 
Sporozoa, 8G5 
Spots, 56 

Spotted disease of Central .America, 
1040 

sickness. 1039 
Spraying, 105 
Squamae, 61 
Squames, 61 
Stains, 56 

St. Anthony's fire. 358 
Staphylococcus opsonic index, deter- 
mination of. 104 
Startin's acid mixture. 924 
Steatoma. 907 

diagnosis, 908 

pathology, 908 

prognosis, 908 

symptoms, 907 

treatment, 908 
St4atome, 907 
Steatorrhcea, 885 

nigricans, 879 



INDEX. 



1123 



Steatorrhea simplex, S8G 
Steatozoon folliculorum, 84G 
Stegomyia fasciata, 864 
Stigmata, bleeding, 882 
Stili dilubiles, 115 

unguentes, 115 
Stinking sweat, 877 
Stomoxis calcitrans, 1026 
Stratum corneum, 28 

disjunctum, 29 

granulosum, 28 

intermedium, 28 

lucidum, 28 

subcutaneum, 20 
Striro patellores, 521 
Strophulus, 1007 
Subcutaneous tissue, 20 
Subungual haemorrhage, 998 

tumor-formation, 998 
Sudamen, 871 

diagnosis, 872 

etiology, 872 

pathology, 872 

symptoms, 871 

treatment, 873 
Sudatoria, 867 
Sudoriparous fat-cysts, 90S 
Sudor sanguineosa, 882 
Suette miliaire, 873 
Sukha-pokla, 1074 
Sulphur, 101, 118 
Summer eruption, recurrent, 410 
Suppurative tubercular lymphangiec- 
tasia, 615 
Sweat, 52 

bloody, 882 

colored, 879 

fetid, 877 

-glands, 867 

-pore, 46 
Sweating sickness, 873 
Sycose, 976 

Sycosiform dermatosis, scar-leaving, 97S 
Sycosis, 976 

diagnosis, 981 
etiology, 979 
pathology, 980 
prognosis, 984 
treatment, 9S1 

coccogenous, 976 

hyphogenous, 799 

lupoid, 978 

" non-parasitic," 976 

nuchae atrophicans, 9S6 

parasitica, 799 

staphylogenes, 976 

vulgaris, 976 
Symmetrical gangrene of extremities, 
369 
etiology, 369 
pathology, 369 
prognosis, 369 
treatment, 369 
Symptomatology, 55 
Symptoms, 55 



Symptoms, objective, 55 

subjective, 5.1 
Synanthemata, <i.~> 
Syndactyly, 98!) 
Synovial lesions of skin, 488 
Syphilide, erythematous, 658 
miliary, 671 
pigmentary, 661 
varicellaform, 669 
Syphilides, 654 
palmar, 667 
plantar, 667 
papulo-squamous, 683 
Syphilis, 647 

diagnosis, 693 
etiology, 689 
pathology, 690 
prognosis, 713 
symptoms, 647 

treatment, 696 
haereditarium, treatment, 712 
fumigation in, 703 
inunction in, 702 
of mucous membranes, 6S2 
of nails, 1004 

acquired, 1004 

hereditary, 1004 

treatment, 1006 
serum tests, 695 
subcutaneous injections in, 704 
" tonic " treatment of, 701 
Syphilitic roseola, 658 
Syphiloderm, acneiform, 671 
circinate, tubercular, 675 
echthymaform, 673 
impetigoform, 672 
papular, 663 

large acuminate, 664 

large flat, 665 

small acuminate, 663 

small flat, 664 
pustular, 671 

large acuminate, 671 

large flat, 673 

small acuminate, 671 

small flat, 672 
pustulo-ulcerative, 673 
varioliform, 671 
Syphiloderma bullosum, 674 
gummatosum, 679 

circumscribed, 679 

diffused, 680 
infantile acquisitum, 684 

haereditarium, 6S4 
maculosum, 658, 661 
papulosum, 663 
pigmentosum, 661 
pustulosum, 670 
tuberculosum, 674 
serpiginosum, 675 
vesiculosum, 669 
Syphilodermata, 654 

local treatment, 710 
Syphilonychia sicca, 1005 
Syringo-cystadenome, 592 



1124 



INDEX. 



Syringocystoma, 592 

diagnosis, 593 
histopathology, 593 

symptoms, 592 
treatment, 593 

Syringoma, 592 

Syringomyelia, 528, 997 



Taclie pigmentaire, 489 
T aches, 56 

ombrccs, 862 
Tactile sense, 53 
Tar, 101, 116 
Taschkat ulcer, 1066 
Taschkent geschwur, 1060 
Tattooing, 535 
Taurine, 102 
Teigne faveuse, 781 

tondante, 796 
Telangiectasia verruqueuse, 470 
Telangiectasis faciei, 930 

generalized, 568 
Telangiectatic granuloma, 572 
Temperature sense, 53 
Terms descriptive of lesions, list of, 66 
Tetia, 1061 

Therapeutics, general, 94 
Thermal changes, 71 
Thiol, 117 
Thiosinamine, 102 
Thyroid extract, 101 
Tick-fever, 1025 

etiology, 1025 
treatment, 1025 
of Rocky Mountains, 44.'! 
Tick, wood-,' 853 
Tinea barbae, 799 
circinata, 793 

tropica. 1037 
decalvans, 966 
favosa, 781 

diagnosis, 787 
etiology, 784 
pathology. 785 
prognosis, 790 
symptoms, 781 
treatment, 787 
unguium, 1003 
imbricata, 1037 

diagnosis, 1039 
etiology, 1039 
pathology, 1039 
prognosis, ]l):!!i 
symptoms, 1038 
treatment. 1039 
kerion, 798 
nodosa. 952 
sycosis, 799 

diagnosis. SOS 
etiology, S02 
pathology, 804 
prognosis, 816 
symptoms, 799 
treatment, 811 



Tinea tonsurans. 796 
"bald," 797 
trichophytina, 790 
cruris, 795 
unguis, 1003 
versicolor, 818 

diagnosis, 821 
etiology, 819 
pathology, 820 
prognosis, 822 
symptoms, 819 
treatment, 822 
Tique, 853 
Toboe, 1061 

Tokelau ringworm, 1037 
Tonga, 1081 
Torcel, 1029 
Toxituberculid.es, 632 
Traumaticin, 115 
Traumatism, 73 
Treatment, external, 106 

internal, 96 
Treponema pallidum, 690 
Trichauxis, 939 
Trichiasis, 941 
Trichoclasia, 947 

Trichoepithelioma papulosum multi- 
plex, 590 
Trichomyco8e nodulaire, 1041 
Trichomycosis nodosa, 951 

palmellina, 951 
Trichonosis cana, 952 
Trichophytie syeosique, 799 
Trichophyton, 802 
Trichoptilosis, 947 
Trichorrexis nodosa, 947 
Trombidae, 849 

Trophoedema, chronic hereditary, 503 
Tropica] chlorosis, 1012 

diseases of uncertain nature, 1069 
Tropics and warm countries, diseases of, 

1007 
Trypanosomiasis, 1021 
symptoms, 1021 

treatment, 1021 
Tubercle, anatomical, 609 
diss,. clion. (J09 
post-mortem, 609 
Tubercles, 58 
Tubercula, 58 

Tubercular lymphangiectasis, suppura- 
tive, 615 
Tuberculide, pigmentary, 036 
Tuberculides, 632 

etiology, 634 
pathology. 635 
symptoms. 634 
treatment. 635 
acnitis tvpe, 634 
folliclis type. 034 
Tuberculoses, verrucous, 611 
Tuberculosis cutis, 602 

diagnosis, 620 
etiology. 616 
pathology, 618 



INDEX. 



1125 



Tuberculosis cutis, prognosis, 029 
symptoms, 603 
treatment, 622 
orificialis, 012 
serpiginosa ulcerativa, 616 
verrucosa, 609 
exanthematic miliary, 616 
fungosa cutis, 615 
of skin, acute, 012 
papillomatosa cutis, 011 
verrucosa cutis, 011 
Tuberculous dactylitis, 015 

eczema, 186, 630 
Tuberose carcinoma, 744 
Tumeurs, 59 
Tumor cavernosus, 568 
Tumores, 59 

benigni sarcoidei cutis, 156 
Tumors, 59 
Turpentine, 101 
Tylosis linguae, 1088 
of nail matrix, 995 
palmarum et plantarum, 461 

IT 

Ulcer, cancroid, 737 
crateriform, 738 
Jacob's, 737 
rodent, 735 
Ulcera, 64 

Ulcerating granuloma of tbe pudenda, 
1005 
diagnosis, 1000 
etiology, 1005 
pathology, 1000 
prognosis, 10GG 
symptoms, 1005 
treatment, 1000 
Ulcerative scrofuloderm, 718 
Ulcers, 04 

exedens, 737 
grave, 1030 
Ulerythema centrifugum, 030 

sycosiforme, 978 
Uncinariasis, 1012 

Unguentum diachyli albi, of Hebra, 214 
Unna's paste, 210 
Uridrose, 881 
Uridrosis, 881 
Urticoe, 58 
Urticaria, 157 

diagnosis, 163 
etiology, 100 
pathology, 10z, 
prognosis, 107 
symptoms, 157 
treatment, 104 
annularis. 159 
bullosa, 159 
chronic, 100 
figurata, 159 
in infants, 160 
in young children, 160 
pigmentosa, 167 
diagnosis, 169 



Urticaria pigmentosa, etiology, 169 
pathology, 169 

symptoms, 107 

treatment, 109 
papulosa, 159 
tuberosa, 159 

vesiculosa, 150 



Vaccination, 438 

bullous eruption following, 441 
Vaccine, 437 
Vaccinia, 437 

pathology, 442 
treatment, 442 
generalized, 442 
haemorrhagic, 440 
Vagabond's disease, 802 
Vajuolo, 424 
Varicella, 435 

diagnosis, 430 
etiology, 430 
pathology, 430 
symptoms, 435 
treatment, 437 
gangrenosa, 307 
Variola, 424 

diagnosis, 432 
etiology, 430 
pathology, 430 
prognosis, 434 
symptoms, 424-4" 9 
treatment, 432 
confluent, 429 
eruption, 425 
haemorrhagic, 428 
initial rashes of, 424 
nigra maligna, 428 
Variolette, 435 
Varioloid, 428 
Variolous erythema, 424 

roseola, 424 
Varnishes, 113 
Varus, 910 
Vaselin, 109 
Vasogen, 115 
Veld sore, 1079 
Venereal wart, 482 
Venerische Granulom, 1065 

Warze, 482 
Ver de Kutigal, 1022 
Vergetures, 520 
Ver macaque, 1029 
Verole, 647 
Verruca, 481 

diagnosis, 485 
etiology, 484 
pathology, 485 
prognosis, 488 
symptoms, 481 
treatment, 487 
acquisita, 482 
congenita, 482 
digitata, 483 
dorsi manus et pedis, 483 



1126 



INDEX. 



Verruca filiformis, 483 
glabra, 483 
necrogenica, 483, 609 
plana, 483 

juvenilis, 483 
seborrheica, 483 
senilis, 483 
vulgaris, 484 
Verruca? acuminata?, 482 
Verrue, 481 

Yerrue-telangiectasique, 470 
Vermes chamues, 556 
Verruga Peruana, 1063 

etiology, 1064 

pathology, 1064 

prognosis, 1064 

symptoms, 1063 

treatment, 1064 
Vesicles, 59 
Vesiculse, 59 
Vespidse, 865 
Visceral disorders, 69 
Vitiligo, 840 

diagnosis, 544 

etiology, 543 

pathology, 544 

prognosis. 545 

symptoms, 540 

treatment. 545 
acquisita syphilitica, 661 
Vitiligoidea, 579 
Vleminckx solution, 107 
Von Recklinghausen's disease, 554 
Vulva and vagina, disorders of, 1098 

carcinoma, 1099 

chancroid, 1098 

dermatitis. 1098 

dermoid cyst, 1099 

elephantiasis. 1099 

inflammations of (vulva). 
1098 

kraurosis. 1099 

lichen planus. 1099 

pemphigus vegetans. 1099 

pruritus, 1098 

sebaceous cysts, 10rr> 

syphilis. 1098 

tuberculosis, 1099 

urethral caruncle. 1099 

verruca acuminata. 1098 

W 

Wart. 481 

moist, 482 

Peruvian, 1061-1063 

venereal. 482 
" Wart-cures," 487 
Warts, soft, 556 
Warze, 481 

Washerman's itch, 1037 
Washerman test in syphilis, 695 
^Y a Kscrpocken, 435 
Water. 99 

externally, 106 
Wen, 907 
Wheals. 58 



Wheals, giant, 58 

White spot disease, 333, 509 

spots, in nails, 993 
Whitlow, 997 

melanotic, 730 
Wood-tick, 853 

X 
Xaxtiielasmoidea, 167 
Xanthoerythrodermia perstans, 305 
Xanthoma, 579 
diagnosis, 583 
etiology, 582 
pathology, 582 
prognosis, 584 
symptoms, 580 
treatment, 584 
Xanthoma diabeticorum, 584 
diagnosis, 585 
etiology, 585 
pathology, 585 
prognosis, 586 
symptoms, 584 
treatment, 586 
elasticum, 582 
generalized, 580 
glycosuria, 584 
papula turn, 624 
planum, 582 
pseudo-elasticum, 586 
solitarium, 581 
tuberosum, 580 
Xeroderma, 494 

pigmentosum, 593 
diagnosis, 599 
etiology, 598 
pathology, 59S 
prognosis, 599 
symptoms, 594 
treatment, 599 
Xerodermia, 494 
Xerosis, 494 
X-ray dermatitis, 274 

treatment, 123, 274 
X-ravs, 72 

Y 
Yaws. 1061 

diagnosis, 1062 
etiology, 1062 
pathology, 1062 
prognosis, 1063. 
symptoms. 1061 
treatment, 1063 



Zona, 374 

Zoster. 374 

abdominalis. 377 
brachialis, 377 
capillitii. 376 
collaris, 377 
facialis. 377 
femoralis, 377 
frontalis, 377 
nuchae, 377 
ophthalmicus, 377 
pectoralis, 377 



SEP 301909 



- v 



MB 

■SB 



HH 



£i§§i 

BBSS 



LIBRARY OF CONGRESS 

"III llll I III III I II 



00Q2b031321 



^'3 



■ 






» 






HHfa 



g%rea6iifg§g 



HSISBhBBSBHBB 



inpH 



